Provider Demographics
NPI:1801167044
Name:GLENDALE DOCTORS MEDICAL CENTER
Entity type:Organization
Organization Name:GLENDALE DOCTORS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TAHSIN
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:WAHEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-242-8805
Mailing Address - Street 1:1123 S. CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2212
Mailing Address - Country:US
Mailing Address - Phone:818-242-8805
Mailing Address - Fax:818-242-4442
Practice Address - Street 1:1123 S. CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2212
Practice Address - Country:US
Practice Address - Phone:818-242-8805
Practice Address - Fax:818-242-4442
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOCTORS HEALTH MEDICAL CENTERS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-19
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9962111N00000X
CAA32929207Q00000X
213E00000X
CAA41065261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty