Basic Information
| Provider Information | |||||||||
| NPI: | 1104005370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARDEHALI | ||||||||
| FirstName: | REZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MEDICAL PLZ | ||||||||
| Address2: | 630 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259011 | ||||||||
| FaxNumber: | 3108259012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A91843 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 282N00000X | A91843 | CA | N | Hospitals | General Acute Care Hospital | 207RC0000X | A91843 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1104005370 | 01 | CA | CCS (MEDICAID) | OTHER | 1104005370 | 05 | CA | MEDICAID |