Provider Demographics
NPI:1013942713
Name:DARDASHTI, SIAMAK (MD)
Entity Type:Individual
Prefix:
First Name:SIAMAK
Middle Name:
Last Name:DARDASHTI
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 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2951
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG803922085P0229X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0106039Medicaid
CA00G803920Medicaid
CABK365ZMedicare PIN
CA00G803922Medicare PIN
CAWG80392CMedicare PIN
CAGR0106039Medicaid
CABM518ZMedicare PIN
CAWG80392KMedicare PIN
CAWG80392MMedicare PIN
CA00G803920Medicaid
CAWG80392BMedicare PIN
CABK365XMedicare PIN
CAWG80392LMedicare PIN
CAWG80392NMedicare PIN
CA00G803928Medicare PIN
CAWG80392AMedicare PIN
CAWG80392GMedicare PIN
CAWG80392PMedicare PIN
CA00G803927Medicare PIN
ARWG80392DMedicare PIN
CAWG80392FMedicare PIN
CAWG80392JMedicare PIN
CAWG80392TMedicare PIN
CABK365YMedicare PIN