Provider Demographics
NPI:1033256573
Name:SAN JUDAS MEDICAL GROUP WEST
Entity Type:Organization
Organization Name:SAN JUDAS MEDICAL GROUP WEST
Other - Org Name:N. ROSTAMI MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NEJAT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSTAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-957-8787
Mailing Address - Street 1:1080 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2310
Mailing Address - Country:US
Mailing Address - Phone:323-957-8787
Mailing Address - Fax:323-957-8777
Practice Address - Street 1:1080 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2310
Practice Address - Country:US
Practice Address - Phone:323-957-8787
Practice Address - Fax:323-957-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067430Medicaid
CAW13920Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER