=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659346021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALI SAJJADIAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2006
-----------------------------------------------------
Last Update Date | 05/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 496 OLD NEWPORT BLVD. SUITE #3
-----------------------------------------------------
City | NEWPORT BLVD.
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-515-0550
-----------------------------------------------------
Fax | 949-515-0551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 496 OLD NEWPORT BLVD SUITE #3
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-4263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-515-0550
-----------------------------------------------------
Fax | 949-515-0551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD056825L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G87722
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------