Provider Demographics
NPI:1689629057
Name:KEDAN, ILAN (MD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:
Last Name:KEDAN
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 1:250 N ROBERTSON BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211
Mailing Address - Country:US
Mailing Address - Phone:310-385-3496
Mailing Address - Fax:310-247-9614
Practice Address - Street 1:250 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
Practice Address - Country:US
Practice Address - Phone:310-385-3496
Practice Address - Fax:310-247-9614
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD034206207RC0000X
CAA93684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035716400Medicaid
MD404855500Medicaid
DCI09090Medicare UPIN
DC035716400Medicaid
VA010087511Medicare ID - Type Unspecified