Provider Demographics
NPI:1861500662
Name:GRODAN, PAUL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOHN
Last Name:GRODAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:150 N ROBERTSON BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2142
Mailing Address - Country:US
Mailing Address - Phone:310-854-0100
Mailing Address - Fax:310-659-3297
Practice Address - Street 1:150 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2142
Practice Address - Country:US
Practice Address - Phone:310-854-0100
Practice Address - Fax:310-659-3297
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG30279207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G302790Medicaid
CAA44357Medicare UPIN
CA00G302790Medicaid