Provider Demographics
NPI:1639509706
Name:MEMORIAL RADIATION ONCOLOGY MEDICAL
Entity Type:Organization
Organization Name:MEMORIAL RADIATION ONCOLOGY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ASIF
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARSOLIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-492-6695
Mailing Address - Street 1:PO BOX 844945
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-4945
Mailing Address - Country:US
Mailing Address - Phone:562-492-6695
Mailing Address - Fax:562-988-0389
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:SUITE LL0300
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-962-7100
Practice Address - Fax:714-963-7600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB212837Medicare PIN