1275684342 NPI number — AVINASH M MONDKAR MD A MEDICAL CORP

Table of content: (NPI 1275684342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275684342 NPI number — AVINASH M MONDKAR MD A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVINASH M MONDKAR MD A MEDICAL CORP
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:
1275684342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8641 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
SUITE 220
Provider Business Mailing Address City Name:
BEVERLY HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90211-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-657-1995
Provider Business Mailing Address Fax Number:
310-657-5311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 N CHINA LAKE BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
RIDGECREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93555-3130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-446-2981
Provider Business Practice Location Address Fax Number:
760-446-2983
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONDKAR
Authorized Official First Name:
AVINASH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-657-1995

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  A35142 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A351420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ04627Z . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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