=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679548556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANJAY V. VADGAMA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 11/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4955 VAN NUYS BLVD 502
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-325-0200
-----------------------------------------------------
Fax | 818-325-0210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4955 VAN NUYS BLVD STE 502
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-325-0200
-----------------------------------------------------
Fax | 818-325-0210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | A80650
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------