Provider Demographics
NPI:1386757086
Name:DEL-CARMEN MEDICAL GROUP
Entity type:Organization
Organization Name:DEL-CARMEN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PIETRUSZKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-914-9150
Mailing Address - Street 1:19234 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5000
Mailing Address - Country:US
Mailing Address - Phone:310-914-9150
Mailing Address - Fax:310-914-9750
Practice Address - Street 1:19234 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5000
Practice Address - Country:US
Practice Address - Phone:310-914-9150
Practice Address - Fax:310-914-9750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A308580Medicaid
CAA26259Medicare UPIN
CA00A308580Medicaid