Provider Demographics
NPI:1912122631
Name:LEO POLOSAJIAN, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LEO POLOSAJIAN, MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:POLOSAJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-718-1600
Mailing Address - Street 1:4930 BALBOA BLVD
Mailing Address - Street 2:NO 261278
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-1278
Mailing Address - Country:US
Mailing Address - Phone:818-718-1600
Mailing Address - Fax:818-718-1920
Practice Address - Street 1:7640 TAMPA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-1735
Practice Address - Country:US
Practice Address - Phone:818-718-1600
Practice Address - Fax:818-718-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174664783OtherPERSONAL NPI NUMBER
CAA81080OtherCA LICENSE NUMBER