Provider Demographics
NPI:1114953643
Name:DAN DARDASHTI, MD INC.
Entity Type:Organization
Organization Name:DAN DARDASHTI, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:ELIA
Authorized Official - Last Name:DARDASHTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-508-9190
Mailing Address - Street 1:12626 RIVERSIDE DR
Mailing Address - Street 2:SUITE #506
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3420
Mailing Address - Country:US
Mailing Address - Phone:818-508-9190
Mailing Address - Fax:818-508-1648
Practice Address - Street 1:12626 RIVERSIDE DR
Practice Address - Street 2:SUITE #506
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3420
Practice Address - Country:US
Practice Address - Phone:818-508-9190
Practice Address - Fax:818-508-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A614570OtherBLUESHIELD
CA00A614570Medicaid
CA00A614570Medicaid
CA=========OtherBLUECROSS