Provider Demographics
NPI:1326006693
Name:WESTSIDE GYNECOLOGY A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WESTSIDE GYNECOLOGY A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:DUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-899-9799
Mailing Address - Street 1:1304 15TH ST
Mailing Address - Street 2:#310
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404
Mailing Address - Country:US
Mailing Address - Phone:310-899-9799
Mailing Address - Fax:310-899-9789
Practice Address - Street 1:1304 15TH ST
Practice Address - Street 2:#310
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-899-9799
Practice Address - Fax:310-899-9789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ547172OtherBLUE SHIELD
CAW14173Medicare ID - Type Unspecified