Provider Demographics
NPI:1609813096
Name:MEDWISE MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:MEDWISE MEDICAL CLINIC, INC
Other - Org Name:MEDWISE MEDICAL CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHALIMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EIVAZZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-242-0500
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-0601
Mailing Address - Country:US
Mailing Address - Phone:818-242-0500
Mailing Address - Fax:
Practice Address - Street 1:540 N CENTRAL AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1916
Practice Address - Country:US
Practice Address - Phone:818-242-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42072208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A420721Medicaid