Provider Demographics
NPI:1003924168
Name:RAHBAN, ALFRED (MDA MEDICAL CORPOR)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:RAHBAN
Suffix:
Gender:M
Credentials:MDA MEDICAL CORPOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4667
Mailing Address - Country:US
Mailing Address - Phone:323-939-3669
Mailing Address - Fax:323-798-1786
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-939-3669
Practice Address - Fax:323-798-1786
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51095207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003924168Medicaid
CG699YMedicare PIN