Provider Demographics
NPI:1134324148
Name:WARDONO, IRA PAULA (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:PAULA
Last Name:WARDONO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRA
Other - Middle Name:PAULA
Other - Last Name:YUSUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7900
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-881-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD431846208000000X
CAA112875208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020378080001Medicaid
PA001993563OtherBLUE SHIELD
PA824184OtherFPH
PA118091Medicare PIN