Provider Demographics
NPI:1114191798
Name:GHANNADI, MAX MAHMOUD (MD,)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:MAHMOUD
Last Name:GHANNADI
Suffix:
Gender:M
Credentials:MD,
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:23679 CALABASAS RD # 327
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1502
Mailing Address - Country:US
Mailing Address - Phone:818-887-5515
Mailing Address - Fax:818-225-9230
Practice Address - Street 1:14103 VICTORY BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91304-3863
Practice Address - Country:US
Practice Address - Phone:818-994-0000
Practice Address - Fax:818-988-2949
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA102618208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABX757AMedicare PIN