Provider Demographics
NPI:1033436464
Name:SAN CRISTOBAL MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SAN CRISTOBAL MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CASILLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-413-4203
Mailing Address - Street 1:1127 WILSHIRE BLVD
Mailing Address - Street 2:STE 820
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3901
Mailing Address - Country:US
Mailing Address - Phone:213-413-4203
Mailing Address - Fax:
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:STE 820
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:213-413-4203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-25
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty