Provider Demographics
NPI:1255479192
Name:COVINA EAR NOSE & THROAT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:COVINA EAR NOSE & THROAT MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GARNER
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-966-2111
Mailing Address - Street 1:202 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1902
Mailing Address - Country:US
Mailing Address - Phone:626-966-2111
Mailing Address - Fax:626-967-6315
Practice Address - Street 1:202 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1902
Practice Address - Country:US
Practice Address - Phone:626-966-2111
Practice Address - Fax:626-967-6315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48653174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A486530Medicaid
CA00A486530Medicaid
CAW843Medicare PIN