Provider Demographics
NPI:1790729846
Name:CHOUDHURY, ESTAK M (MD)
Entity Type:Individual
Prefix:DR
First Name:ESTAK
Middle Name:M
Last Name:CHOUDHURY
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 1:1756 HERRIN ST
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2828
Mailing Address - Country:US
Mailing Address - Phone:909-289-2124
Mailing Address - Fax:
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6098
Practice Address - Country:US
Practice Address - Phone:323-913-4892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74269207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H69311Medicare UPIN