Provider Demographics
NPI:1245249325
Name:PUTHAWALA, AJMEL A (MD)
Entity type:Individual
Prefix:DR
First Name:AJMEL
Middle Name:A
Last Name:PUTHAWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2650 ELM AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1651
Mailing Address - Country:US
Mailing Address - Phone:562-492-6695
Mailing Address - Fax:562-988-0389
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:SUITE 0300
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-962-7100
Practice Address - Fax:714-963-7600
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA293512085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29351OtherLICENSE
CA00A029351Medicaid
AP6611861OtherDEA
WA29351HMedicare ID - Type Unspecified
CA00A029351Medicaid
AP6611861OtherDEA
WA29351EMedicare ID - Type Unspecified