Provider Demographics
NPI:1164503371
Name:MULTI DIAGNOSTIC IMAGING AND BREAST CENTER MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:MULTI DIAGNOSTIC IMAGING AND BREAST CENTER MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHOSROW
Authorized Official - Middle Name:
Authorized Official - Last Name:SADRIEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-986-8215
Mailing Address - Street 1:4910 VAN NUYS BLVD
Mailing Address - Street 2:110
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1782
Mailing Address - Country:US
Mailing Address - Phone:818-986-8215
Mailing Address - Fax:818-986-9582
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:110
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1782
Practice Address - Country:US
Practice Address - Phone:818-986-8215
Practice Address - Fax:818-986-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29572174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ48958ZOtherBLUE SHIELD PROVIDER NUMB
CAZZZ97621ZOtherBLUE CROSS PROVIDER NUMBE
CA00A295720Medicaid
CAZZZ48958ZOtherBLUE SHIELD PROVIDER NUMB
CAZZZ97621ZOtherBLUE CROSS PROVIDER NUMBE