Provider Demographics
NPI:1326299496
Name:DERMATOLOGY & LASER MEDICAL CTR INC
Entity Type:Organization
Organization Name:DERMATOLOGY & LASER MEDICAL CTR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHADAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-528-2500
Mailing Address - Street 1:PO BOX 261430
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-1430
Mailing Address - Country:US
Mailing Address - Phone:661-575-0003
Mailing Address - Fax:661-575-0006
Practice Address - Street 1:16260 VENTURA BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2203
Practice Address - Country:US
Practice Address - Phone:818-528-2500
Practice Address - Fax:818-528-2505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71517207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH70923Medicare UPIN
CAW16663Medicare PIN