Provider Demographics
NPI:1710984208
Name:KANGAVARI, SIMON (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:KANGAVARI
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 1:501 E HARDY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4054
Mailing Address - Country:US
Mailing Address - Phone:310-672-3900
Mailing Address - Fax:310-671-8438
Practice Address - Street 1:501 E HARDY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4054
Practice Address - Country:US
Practice Address - Phone:310-672-3900
Practice Address - Fax:310-671-8438
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4170981OtherAPEX CARDIOLOGY PROV ID
CAW10766OtherMEDICARE PROVIDER ID
CAA69521OtherMEDICAL LICENSE
CAWA69521BMedicare ID - Type UnspecifiedMEDICARE PPIN