Basic Information
| Provider Information | |||||||||
| NPI: | 1902062136 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EL PORTAL RADIATION ONCOLOGY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 23779 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911853779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097263410 | ||||||||
| FaxNumber: | 2097263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 M ST | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953482714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097263371 | ||||||||
| FaxNumber: | 2097263410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2008 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | MAHMOUDIEH | ||||||||
| AuthorizedOfficialFirstName: | ALIREZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2097263371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.