Provider Demographics
NPI:1699086876
Name:R S VASAN M D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:R S VASAN M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANGACHARI
Authorized Official - Middle Name:SRINI
Authorized Official - Last Name:VASAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-782-4104
Mailing Address - Street 1:15243 VANOWEN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3605
Mailing Address - Country:US
Mailing Address - Phone:818-782-4104
Mailing Address - Fax:818-782-0231
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3627
Practice Address - Country:US
Practice Address - Phone:818-782-4104
Practice Address - Fax:818-782-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33733174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A337330Medicaid
CAA33733Medicare PIN
CA00A337330Medicaid