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General NPI Number Information
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NPI Number | 1902045040
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Entity Type | Organization
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Legal Business Name | GRAIDUKEL MED INC
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Dates
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Enumeration Date | 02/12/2009
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Last Update Date | 02/12/2009
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Provider Practice Location Address
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Address Line | 2750 E WASHINGTON BLVD SUITE #370
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City | PASADENA
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State | CA
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Zip | 91107-1448
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Country | US
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Telephone | 626-296-0792
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 50082
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City | PASADENA
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State | CA
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Zip | 91115-0082
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Country | US
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Telephone | 626-296-0792
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | IDUAMA KELLY-DOKUBO
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Credential | M.D.
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Telephone | 626-296-0792
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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