Provider Demographics
NPI:1417050782
Name:LADDARAN MEDICAL GROUP
Entity Type:Organization
Organization Name:LADDARAN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:CHUA
Authorized Official - Last Name:LADDARAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-413-8742
Mailing Address - Street 1:2105 BEVERLY BLVD
Mailing Address - Street 2:STE 117
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057
Mailing Address - Country:US
Mailing Address - Phone:213-413-8742
Mailing Address - Fax:213-413-6482
Practice Address - Street 1:2105 BEVERLY BLVD
Practice Address - Street 2:STE 117
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057
Practice Address - Country:US
Practice Address - Phone:213-413-8742
Practice Address - Fax:213-413-6482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA365070208000000X
CAA3659102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064390Medicaid
CAGR0064390Medicaid