Provider Demographics
NPI:1104373745
Name:INTEGRATIVE DIAGNOSTIC GROUP INC
Entity Type:Organization
Organization Name:INTEGRATIVE DIAGNOSTIC GROUP INC
Other - Org Name:INTEGRATIVE DIAGNOSTIC GROUP INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GANGHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-653-0180
Mailing Address - Street 1:1231 ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2750
Mailing Address - Country:US
Mailing Address - Phone:562-653-0180
Mailing Address - Fax:562-402-3029
Practice Address - Street 1:12231 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2750
Practice Address - Country:US
Practice Address - Phone:562-653-0180
Practice Address - Fax:562-402-3029
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE DIAGNOSTIC GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30411207QA0505X
CAPSY6247323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972824753Medicaid