1912122631 NPI number — LEO POLOSAJIAN, MD, A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1912122631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912122631 NPI number — LEO POLOSAJIAN, MD, A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEO POLOSAJIAN, MD, A PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912122631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4930 BALBOA BLVD
Provider Second Line Business Mailing Address:
NO 261278
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91426-1278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-718-1600
Provider Business Mailing Address Fax Number:
818-718-1920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7640 TAMPA AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RESEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91335-1735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-718-1600
Provider Business Practice Location Address Fax Number:
818-718-1920
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POLOSAJIAN
Authorized Official First Name:
LEO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-718-1600

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1174664783 . This is a "PERSONAL NPI NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A81080 . This is a "CA LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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