Provider Demographics
NPI:1366491888
Name:CITRUS VALLEY UROLOGIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CITRUS VALLEY UROLOGIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:626-914-3921
Mailing Address - Street 1:412 WEST CARROLL AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4264
Mailing Address - Country:US
Mailing Address - Phone:626-914-3921
Mailing Address - Fax:626-914-9611
Practice Address - Street 1:412 WEST CARROLL AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4264
Practice Address - Country:US
Practice Address - Phone:626-914-3921
Practice Address - Fax:626-914-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208800000X
CA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ726372Medicaid
CAW1349AMedicare UPIN
CAA41263Medicare UPIN