Provider Demographics
NPI:1649205576
Name:ARDEHALI, ABBAS (MD)
Entity Type:Individual
Prefix:
First Name:ABBAS
Middle Name:
Last Name:ARDEHALI
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE RM 62-186
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-5841
Practice Address - Fax:310-206-3506
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62746207RC0000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G627460Medicaid
CAF32649Medicare UPIN
CAWG62746CMedicare PIN
CAGH134ZMedicare PIN