Provider Demographics
NPI:1538212170
Name:LOS ANGELES UROLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:LOS ANGELES UROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:323-261-0108
Mailing Address - Street 1:1701 E CESAR E CHAVEZ AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2464
Mailing Address - Country:US
Mailing Address - Phone:323-261-0108
Mailing Address - Fax:323-224-6206
Practice Address - Street 1:1701 E CESAR E CHAVEZ AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2464
Practice Address - Country:US
Practice Address - Phone:323-261-0108
Practice Address - Fax:323-224-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54840208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063220Medicaid
CAW13150Medicare ID - Type Unspecified