Basic Information
| Provider Information | |||||||||
| NPI: | 1831485994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL DIAGNOSTICS AND REHABILITATION CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16952 VENTURA BLVD., SUITE 200-A | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913164198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187893964 | ||||||||
| FaxNumber: | 8187893967 | ||||||||
| Practice Location | |||||||||
| Address1: | 16952 VENTURA BLVD., SUITE 200-A | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913164198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187893964 | ||||||||
| FaxNumber: | 8187893967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 06/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | SHIRAZY | ||||||||
| AuthorizedOfficialFirstName: | PEJMAN | ||||||||
| AuthorizedOfficialMiddleName: | ELI | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8187893964 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A76100 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.