Provider Demographics
NPI:1467464156
Name:GHIASSI, ALIDAD (MD)
Entity Type:Individual
Prefix:DR
First Name:ALIDAD
Middle Name:
Last Name:GHIASSI
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 1:11645 WILSHIRE BLVD STE 702
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6807
Mailing Address - Country:US
Mailing Address - Phone:310-824-1261
Mailing Address - Fax:310-824-5190
Practice Address - Street 1:11645 WILSHIRE BLVD STE 702
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6807
Practice Address - Country:US
Practice Address - Phone:310-824-1261
Practice Address - Fax:310-824-5190
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60348207XS0106X
CAA060348174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0646540001Medicare NSC
CAW9002Medicare PIN
CAH03441Medicare UPIN