Provider Demographics
NPI:1043241136
Name:VALLEY INFECTIONS DISEASE MEDICAL GROUP INC A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:VALLEY INFECTIONS DISEASE MEDICAL GROUP INC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLSWORTH
Authorized Official - Middle Name:PAXTON
Authorized Official - Last Name:PRYOR, III
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-255-8544
Mailing Address - Street 1:23928 LYONS AVE
Mailing Address - Street 2:#208
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2409
Mailing Address - Country:US
Mailing Address - Phone:661-255-8544
Mailing Address - Fax:661-255-9964
Practice Address - Street 1:23928 LYONS AVE
Practice Address - Street 2:#208
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2409
Practice Address - Country:US
Practice Address - Phone:661-255-8544
Practice Address - Fax:661-255-9964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G298800Medicaid
CAA44206Medicare UPIN
CAG29880Medicare ID - Type Unspecified