Basic Information
| Provider Information | |||||||||
| NPI: | 1952459513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AHLUWALIA | ||||||||
| FirstName: | SANJIVENDRA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 SHELDON ST | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902453915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103224278 | ||||||||
| FaxNumber: | 3103226660 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 CENTURY PARK E | ||||||||
| Address2: | SUITE #1204 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900672001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104301310 | ||||||||
| FaxNumber: | 3108700322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A85203 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 954664561 | 01 | CA | TAX ID | OTHER |