Provider Demographics
NPI:1598797375
Name:PORDELL, REZA (MD)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:PORDELL
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:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-445-2983
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-445-2983
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA368782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A368780OtherBLUE SHIELD
CAWA36878GMedicare ID - Type Unspecified
CAWA36878CMedicare ID - Type Unspecified
CAC49464Medicare UPIN
CATP018Medicare ID - Type Unspecified
CAWA36878DMedicare ID - Type Unspecified
CATG056Medicare ID - Type Unspecified
CATP016AMedicare ID - Type Unspecified
CATP051Medicare ID - Type Unspecified
CA00A368780OtherBLUE SHIELD
CATG054Medicare ID - Type Unspecified
CATG256BMedicare ID - Type Unspecified
CA00A368781Medicare ID - Type Unspecified
CATG055Medicare ID - Type Unspecified
CATP009Medicare ID - Type Unspecified
CAWA36878BMedicare ID - Type Unspecified
CAWA36878EMedicare ID - Type Unspecified
CAWA36878FMedicare ID - Type Unspecified
CA00A368780Medicare ID - Type Unspecified