MEDICARE: ORTAL POULDAR PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	90096	CA

General Provider Information

NPI Number	:	1588330161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ORTAL POULDAR PA

Provider Business Mailing Address
First Line	:	5600 WILSHIRE BLVD STE A
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3797
Country	:	US
Telephone Number	:	310-404-6493
Fax Number	:

Provider Business Practice Location Address
First Line	:	5600 WILSHIRE BLVD STE A
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3797
Country	:	US
Telephone Number	:	310-404-6493
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	02/17/2026

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Directions to “ ORTAL POULDAR PA” Practice Location

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