Basic Information
| Provider Information | |||||||||
| NPI: | 1376565374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARSOLIA | ||||||||
| FirstName: | ASIF | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2650 ELM AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18111 BROOKHURST ST | ||||||||
| Address2: | STE 0300 | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927086728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149627100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 35670 | AZ | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | A99453 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CR688X | 01 | CA | PTAN | OTHER | A99453 | 01 | CA | STATE LICENSE | OTHER | 0927400 | 01 | AZ | BCBS AZ PROVIDER # | OTHER | 7368874 | 01 | AZ | AETNA PROVIDER # | OTHER | 7905964 | 01 | AZ | CIGNA PROVIDER # | OTHER | 125097 | 05 | AZ | MEDICAID | 125097 | 01 | AZ | CARE 1ST HLTH. PLAN # | OTHER |