Provider Demographics
NPI:1245740331
Name:TDJ MD GROUP INC
Entity Type:Organization
Organization Name:TDJ MD GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DOSUMU-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-733-9789
Mailing Address - Street 1:12826 VICTORY BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3065
Mailing Address - Country:US
Mailing Address - Phone:818-583-0050
Mailing Address - Fax:
Practice Address - Street 1:12826 VICTORY BLVD STE E
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3065
Practice Address - Country:US
Practice Address - Phone:818-583-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty