Basic Information
| Provider Information | |||||||||
| NPI: | 1245249325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUTHAWALA | ||||||||
| FirstName: | AJMEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 ELM AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | 5629880389 | ||||||||
| Practice Location | |||||||||
| Address1: | 18111 BROOKHURST ST | ||||||||
| Address2: | SUITE 0300 | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927086728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149627100 | ||||||||
| FaxNumber: | 7149637600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2006 | ||||||||
| LastUpdateDate: | 10/01/2012 | ||||||||
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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 | 2085R0001X | A29351 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | A29351 | 01 | CA | LICENSE | OTHER | 00A029351 | 05 | CA | MEDICAID | AP6611861 | 01 | DEA | OTHER |