Provider Demographics
NPI:1376564401
Name:GHADISHAH, IRADJ (MD)
Entity Type:Individual
Prefix:
First Name:IRADJ
Middle Name:
Last Name:GHADISHAH
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 1:10660 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1108
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4522
Mailing Address - Country:US
Mailing Address - Phone:310-470-8220
Mailing Address - Fax:
Practice Address - Street 1:9808 VENICE BLVD
Practice Address - Street 2:SUITE 710
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2732
Practice Address - Country:US
Practice Address - Phone:310-470-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50282208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50282DMedicare ID - Type Unspecified