Provider Demographics
NPI:1912930710
Name:SAN FERNANDO VALLEY UROL ASSOC MED
Entity Type:Organization
Organization Name:SAN FERNANDO VALLEY UROL ASSOC MED
Other - Org Name:SAN FERNANDO VALLEY UROLOGICAL ASSOCIATES MEDICAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-996-4242
Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:STE 407
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2804
Mailing Address - Country:US
Mailing Address - Phone:818-996-4242
Mailing Address - Fax:818-996-4352
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:STE 407
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2804
Practice Address - Country:US
Practice Address - Phone:818-996-4242
Practice Address - Fax:818-996-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ16738ZOtherBLUE SHIELD
CAZZZ49135ZMedicaid
CACP5338OtherRAILROAD MEDICARE
CACP5338OtherRAILROAD MEDICARE
CAW562Medicare PIN