Provider Demographics
NPI:1215298286
Name:WESTERN PODMED CLINIC INC
Entity type:Organization
Organization Name:WESTERN PODMED CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-243-0400
Mailing Address - Street 1:1500 S CENTRAL AVE
Mailing Address - Street 2:SUITE 323
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2530
Mailing Address - Country:US
Mailing Address - Phone:818-243-0400
Mailing Address - Fax:818-507-9902
Practice Address - Street 1:1500 S CENTRAL AVE
Practice Address - Street 2:SUITE 323
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-3858
Practice Address - Country:US
Practice Address - Phone:818-243-0400
Practice Address - Fax:818-507-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4513213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty