Provider Demographics
NPI:1366912446
Name:VASCULAR COSMETICS LA
Entity type:Organization
Organization Name:VASCULAR COSMETICS LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODAVERDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-482-0016
Mailing Address - Street 1:19 HEATHER HILL LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-6043
Mailing Address - Country:US
Mailing Address - Phone:801-641-1344
Mailing Address - Fax:818-484-8243
Practice Address - Street 1:1511 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-1912
Practice Address - Country:US
Practice Address - Phone:818-482-0016
Practice Address - Fax:818-484-8243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA127413OtherMED LICENSE