Provider Demographics
NPI:1477755528
Name:NAWATHE, AMAR C (MD)
Entity Type:Individual
Prefix:DR
First Name:AMAR
Middle Name:C
Last Name:NAWATHE
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8713
Mailing Address - Fax:
Practice Address - Street 1:1250 16TH ST # C2304
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-319-4698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO8281700207R00000X, 208M00000X
CAA96528207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0139360Medicaid
NJ0139360Medicaid