Provider Demographics
NPI:1124192620
Name:FOULADIAN, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FOULADIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10660 WILSHIRE BLVD APT 608
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-7348
Mailing Address - Country:US
Mailing Address - Phone:310-985-2020
Mailing Address - Fax:
Practice Address - Street 1:403 N PACIFIC COAST HWY
Practice Address - Street 2:#108
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2839
Practice Address - Country:US
Practice Address - Phone:310-318-6665
Practice Address - Fax:310-318-7117
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9702152W00000X
CABOL5070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6784926Medicaid
CAOP970202CMedicare PIN