Basic Information
| Provider Information | |||||||||
| NPI: | 1073988614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODLAND HILLS MEDICAL CLINIC INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WOODLAND HILLS MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 19825 VENTURA BLVD. | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887009 | ||||||||
| FaxNumber: | 8188887018 | ||||||||
| Practice Location | |||||||||
| Address1: | 19825 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913642627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887009 | ||||||||
| FaxNumber: | 8188887018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2015 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIRSHOJAE | ||||||||
| AuthorizedOfficialFirstName: | HAMID | ||||||||
| AuthorizedOfficialMiddleName: | REZA | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8188887009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 20A6577 | CA | Y | Hospitals | Special Hospital |
No ID Information.