Provider Demographics
NPI:1962912246
Name:BIOGENX MEDICAL
Entity type:Organization
Organization Name:BIOGENX MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:OTIKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-836-2475
Mailing Address - Street 1:620 S GLENDORA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6815
Mailing Address - Country:US
Mailing Address - Phone:818-836-2475
Mailing Address - Fax:310-943-1475
Practice Address - Street 1:620 S GLENDORA AVE STE B
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6815
Practice Address - Country:US
Practice Address - Phone:818-836-2475
Practice Address - Fax:310-943-1475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG776662083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77666OtherCALIFORNIA MEDICAL LICENSE