Provider Demographics
NPI:1962686477
Name:DR. NASSER REDJAL M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DR. NASSER REDJAL M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NASSER
Authorized Official - Middle Name:
Authorized Official - Last Name:REDJAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-782-2332
Mailing Address - Street 1:15243 VANOWEN ST
Mailing Address - Street 2:STE. 304
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:STE. 304
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-782-2332
Practice Address - Fax:818-782-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41807174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A418071Medicaid
CA00A418071Medicaid
CAW21756Medicare PIN