Provider Demographics
NPI:1316049463
Name:GARY L ZAGELBAUM, MD A PROF CORP
Entity type:Organization
Organization Name:GARY L ZAGELBAUM, MD A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZAGELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-857-1323
Mailing Address - Street 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1504
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5816
Mailing Address - Country:US
Mailing Address - Phone:323-857-1323
Mailing Address - Fax:323-857-7089
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1504
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5816
Practice Address - Country:US
Practice Address - Phone:323-857-1323
Practice Address - Fax:323-857-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36630207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A38046Medicare UPIN
CAG36630Medicare PIN