Provider Demographics
NPI:1609821057
Name:WADHWANI, ANIL (MD)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:
Last Name:WADHWANI
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:DEPT LA 21559
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1559
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:
Practice Address - Street 1:2202 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5706
Practice Address - Country:US
Practice Address - Phone:310-264-9000
Practice Address - Fax:310-264-9004
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA789802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A789800Medicaid
CA00A789800OtherBLUE SHIELD OF CA
CA00A789800Medicaid
CAWA78980HMedicare PIN
CAWA78980LMedicare PIN
CA00A789800OtherBLUE SHIELD OF CA
CAWA78980IMedicare PIN
CAWA78980KMedicare PIN
CAP00016121Medicare PIN
CAP00066918Medicare PIN