Provider Demographics
NPI:1518014463
Name:SAN FERNANDO VALLEY VASCULAR GROUP A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SAN FERNANDO VALLEY VASCULAR GROUP A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FUAD
Authorized Official - Middle Name:F
Authorized Official - Last Name:RAFIDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-345-6126
Mailing Address - Street 1:18226 VENTURA BOULEVARD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4246
Mailing Address - Country:US
Mailing Address - Phone:818-345-6126
Mailing Address - Fax:818-345-5061
Practice Address - Street 1:18840 VENTURA BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3301
Practice Address - Country:US
Practice Address - Phone:818-345-6126
Practice Address - Fax:818-345-5061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA062315174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2648Medicare PIN