Provider Demographics
NPI:1275537524
Name:DARDASHTI, DAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:E
Last Name:DARDASHTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12626 RIVERSIDE DR
Mailing Address - Street 2:STE 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:STE 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A614570Medicaid
CAW19577Medicare ID - Type Unspecified
CAG91592Medicare UPIN