Provider Demographics
NPI:1184735235
Name:KIDNEY SPECIALISTS MEDICAL CORPORATION
Entity type:Organization
Organization Name:KIDNEY SPECIALISTS MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D./PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DORSA
Authorized Official - Middle Name:F
Authorized Official - Last Name:MARYSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-722-7418
Mailing Address - Street 1:101 E BEVERLY BLVD
Mailing Address - Street 2:SUITE #304
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4300
Mailing Address - Country:US
Mailing Address - Phone:323-722-7418
Mailing Address - Fax:323-722-7894
Practice Address - Street 1:101 E BEVERLY BLVD
Practice Address - Street 2:SUITE #304
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4300
Practice Address - Country:US
Practice Address - Phone:323-722-7418
Practice Address - Fax:323-722-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080920Medicaid
CAGR0080920Medicaid