Provider Demographics
NPI:1740392810
Name:KIDNEY DISEASE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:KIDNEY DISEASE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE GROUP
Authorized Official - Prefix:
Authorized Official - First Name:DARIUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:ARFAANIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-500-4055
Mailing Address - Street 1:1505 WILSON TER
Mailing Address - Street 2:SUITE #155
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4071
Mailing Address - Country:US
Mailing Address - Phone:818-500-4055
Mailing Address - Fax:818-500-4065
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:SUITE #155
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-500-4055
Practice Address - Fax:818-500-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A343610Medicaid
CA00A529500Medicaid
CA00A608910Medicaid
WA60891AMedicare ID - Type Unspecified
WA52950BMedicare ID - Type Unspecified
CA00A529500Medicaid
CA00A343610Medicaid
H28964Medicare UPIN
CA00A608910Medicaid