1528459385 NPI number — GASTROENTEROLOGY MEDICAL OF LOS ANGELES INC

Table of content: (NPI 1528459385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528459385 NPI number — GASTROENTEROLOGY MEDICAL OF LOS ANGELES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY MEDICAL OF LOS ANGELES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1528459385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 S ATLANTIC BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MONTEREY PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91754-6700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-284-1350
Provider Business Mailing Address Fax Number:
626-284-2454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 S ATLANTIC BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MONTEREY PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91754-6700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-284-1350
Provider Business Practice Location Address Fax Number:
626-284-2454
Provider Enumeration Date:
02/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
IBARRA
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
626-284-1350

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  A38493 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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