Provider Demographics
NPI:1316970866
Name:HADADZ, ALI (MD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:HADADZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALI
Other - Middle Name:
Other - Last Name:HADDADZADEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4560 ADMIRALTY WAY STE 303
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5426
Mailing Address - Country:US
Mailing Address - Phone:310-204-5510
Mailing Address - Fax:424-384-5053
Practice Address - Street 1:4560 ADMIRALTY WAY STE 303
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5426
Practice Address - Country:US
Practice Address - Phone:310-204-5510
Practice Address - Fax:424-384-5053
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69816208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA010066259OtherMEDICARE RAILROAD
CAZZZ05665ZOtherBLUE SHIELD CA
CA00A698160Medicaid
CAZZZ05665ZOtherBLUE SHIELD CA
CA00A698160Medicaid