Provider Demographics
NPI:1679609622
Name:LEILIE JAVAN, M.D., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:LEILIE JAVAN, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LEILIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-495-0551
Mailing Address - Street 1:425 HAALAND DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5229
Mailing Address - Country:US
Mailing Address - Phone:805-381-9800
Mailing Address - Fax:805-496-8480
Practice Address - Street 1:425 HAALAND DR
Practice Address - Street 2:SUITE 203
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-5229
Practice Address - Country:US
Practice Address - Phone:805-381-9800
Practice Address - Fax:805-496-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8610102086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG86101AMedicare UPIN
CAH64791Medicare UPIN
CAW19546Medicare ID - Type Unspecified