Provider Demographics
NPI:1992884738
Name:ROBERT G PUGACH MD INC
Entity type:Organization
Organization Name:ROBERT G PUGACH MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:PUGACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-594-0860
Mailing Address - Street 1:3801 KATELLA AVE
Mailing Address - Street 2:#110
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720
Mailing Address - Country:US
Mailing Address - Phone:562-594-0860
Mailing Address - Fax:562-594-9010
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:#110
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720
Practice Address - Country:US
Practice Address - Phone:562-594-0860
Practice Address - Fax:562-594-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41822208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A418220Medicaid
CAW18333Medicare ID - Type Unspecified
B50478Medicare UPIN