Provider Demographics
NPI:1730271099
Name:KHODADADI, ARBI (MD)
Entity type:Individual
Prefix:
First Name:ARBI
Middle Name:
Last Name:KHODADADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 TIVERTON AVE
Mailing Address - Street 2:113
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3000
Mailing Address - Country:US
Mailing Address - Phone:805-886-4339
Mailing Address - Fax:
Practice Address - Street 1:959 E WALNUT ST
Practice Address - Street 2:SUITE 120
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1451
Practice Address - Country:US
Practice Address - Phone:626-304-0782
Practice Address - Fax:626-795-8603
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83304207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA109514Medicare UPIN