Provider Demographics
NPI:1013979822
Name:SADRIEH, ALI REZA
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:REZA
Last Name:SADRIEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1360
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91614-0360
Mailing Address - Country:US
Mailing Address - Phone:310-691-5411
Mailing Address - Fax:310-388-1658
Practice Address - Street 1:12265 VENTURA BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2528
Practice Address - Country:US
Practice Address - Phone:310-691-5411
Practice Address - Fax:310-388-1658
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4318213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU85754Medicare UPIN
CAE4318BMedicare PIN