Basic Information
| Provider Information | |||||||||
| NPI: | 1508081969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEPAHDARI | ||||||||
| FirstName: | ALI | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103016800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900953075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103016800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 03/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 36117841 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A113928 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001088602 | 01 | MA | MEDICARE ACD | OTHER | 0A1139280 | 05 | CA | MEDICAID | 2174341 | 05 | MA | MEDICAID | 001088601 | 01 | MA | MEDICARE PROVIDER | OTHER |