Provider Demographics
NPI:1710978135
Name:QOZI-HABASH, TEDMUR (MD)
Entity Type:Individual
Prefix:
First Name:TEDMUR
Middle Name:
Last Name:QOZI-HABASH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 FLOWER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3015
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-242-8761
Practice Address - Street 1:14901 RINALDI ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1204
Practice Address - Country:US
Practice Address - Phone:818-365-8553
Practice Address - Fax:818-365-4524
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A910260Medicaid
CAI46937Medicare UPIN
CAWA91026AMedicare PIN