Provider Demographics
NPI:1124214150
Name:ALI JOHN ENAYATI MD MPH PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ALI JOHN ENAYATI MD MPH PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:ALI JOHN ENAYATI MD MPH, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LIZANNE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-298-6422
Mailing Address - Street 1:2080 CENTURY PARK E STE 1806
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2009
Mailing Address - Country:US
Mailing Address - Phone:310-551-1711
Mailing Address - Fax:310-551-1311
Practice Address - Street 1:2080 CENTURY PARK E STE 1806
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2021
Practice Address - Country:US
Practice Address - Phone:310-551-1711
Practice Address - Fax:310-551-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19702Medicare PIN
CAWA73998FMedicare PIN