Provider Demographics
NPI:1962400028
Name:SAN GABRIEL PEDIATRICS MEDICAL CORPORATION
Entity type:Organization
Organization Name:SAN GABRIEL PEDIATRICS MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MEZIA
Authorized Official - Middle Name:OGUGUA
Authorized Official - Last Name:AZINGE-OBASI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-290-2832
Mailing Address - Street 1:3450 W 43RD ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-4943
Mailing Address - Country:US
Mailing Address - Phone:323-290-2832
Mailing Address - Fax:323-290-2836
Practice Address - Street 1:3450 W 43RD ST
Practice Address - Street 2:SUITE 107
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-4943
Practice Address - Country:US
Practice Address - Phone:323-290-2832
Practice Address - Fax:323-290-2836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53449261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A534492Medicaid
CA00A534491Medicaid
CA00A534490Medicaid
CA00A534490Medicaid
CA00A534491Medicaid
CAG13159Medicare UPIN
CAA53449Medicare ID - Type UnspecifiedROSEMEAD