Provider Demographics
NPI:1386748614
Name:PID ASSOCIATES MEDICAL GROUP INC
Entity type:Organization
Organization Name:PID ASSOCIATES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVEIKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-933-8590
Mailing Address - Street 1:1536 W 25TH ST
Mailing Address - Street 2:PMB 163
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-4415
Mailing Address - Country:US
Mailing Address - Phone:562-933-8590
Mailing Address - Fax:562-933-8093
Practice Address - Street 1:2801 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1701
Practice Address - Country:US
Practice Address - Phone:562-933-8590
Practice Address - Fax:562-933-8093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA408962080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP144665OtherCCS/CHP NUMBER
CAGR0041670Medicaid
CAW13422Medicare ID - Type Unspecified