Provider Demographics
NPI:1184817496
Name:KEVIN PEZESHKI MD INC
Entity Type:Organization
Organization Name:KEVIN PEZESHKI MD INC
Other - Org Name:SAN JOSEPH MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEZESHKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-909-9955
Mailing Address - Street 1:13750 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-2324
Mailing Address - Country:US
Mailing Address - Phone:818-909-9955
Mailing Address - Fax:818-909-0454
Practice Address - Street 1:13750 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-2324
Practice Address - Country:US
Practice Address - Phone:818-909-9955
Practice Address - Fax:818-909-0454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67148174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090250Medicaid
CAH02140Medicare UPIN
CAGR0090250Medicaid