Provider Demographics
NPI:1346429313
Name:CANOGA PARK MEDICAL GROUP A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:CANOGA PARK MEDICAL GROUP A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERLMUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-347-3077
Mailing Address - Street 1:7301 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 405
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1904
Mailing Address - Country:US
Mailing Address - Phone:818-347-3077
Mailing Address - Fax:818-347-8334
Practice Address - Street 1:7301 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 405
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1904
Practice Address - Country:US
Practice Address - Phone:818-347-3077
Practice Address - Fax:818-347-8334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA28598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ72255ZMedicaid
CAZZZ72255ZMedicaid