Provider Demographics
NPI:1346302114
Name:ELITE ONCOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:ELITE ONCOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MEDICAL ONCOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:NAZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-BUSSAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-397-8654
Mailing Address - Street 1:12405 VENICE BLVD # 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3803
Mailing Address - Country:US
Mailing Address - Phone:310-397-8654
Mailing Address - Fax:310-398-4470
Practice Address - Street 1:12099 W WASHINGTON BLVD STE 304
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-2621
Practice Address - Country:US
Practice Address - Phone:310-398-0013
Practice Address - Fax:310-398-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA026479174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty