Provider Demographics
NPI:1982708384
Name:DANDAN, IMAD S (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:S
Last Name:DANDAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9888 GENESEE AVE
Mailing Address - Street 2:LJ-601
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1205
Mailing Address - Country:US
Mailing Address - Phone:858-626-6362
Mailing Address - Fax:858-626-6354
Practice Address - Street 1:9888 GENESEE AVE
Practice Address - Street 2:LJ-601
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-626-6362
Practice Address - Fax:858-626-6354
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA458932086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A458930Medicaid
CAW18942Medicare ID - Type Unspecified
CA00A458930Medicaid