Provider Demographics
NPI:1932153731
Name:BISWAS, MAHUA (MD)
Entity Type:Individual
Prefix:
First Name:MAHUA
Middle Name:
Last Name:BISWAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6629
Mailing Address - Country:US
Mailing Address - Phone:310-836-1574
Mailing Address - Fax:310-836-6925
Practice Address - Street 1:4640 ADMIRALTY WAY
Practice Address - Street 2:SUITE 102
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6629
Practice Address - Country:US
Practice Address - Phone:310-836-1574
Practice Address - Fax:310-836-6925
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA485752085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A485750Medicaid
CAW13956Medicare PIN
CAWA48575DMedicare ID - Type Unspecified
CAHW13956Medicare PIN
CAF12198Medicare UPIN
CA00A485750Medicaid
CAHW8434Medicare PIN