Basic Information
| Provider Information | |||||||||
| NPI: | 1740236280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRODEN | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15910 VENTURA BLVD | ||||||||
| Address2: | SUITE 1502 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187289877 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15910 VENTURA BLVD | ||||||||
| Address2: | SUITE 1502 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187289877 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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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 | 207L00000X | G65019 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0000X | G65019 | CA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | G65019 | CA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G650190 | 05 | CA | MEDICAID | 00G650190 | 01 | CA | BLUE SHIELD | OTHER |