Provider Demographics
NPI:1376580894
Name:MEDIPRO INC.
Entity Type:Organization
Organization Name:MEDIPRO INC.
Other - Org Name:MEDIPLUS MULTISPECIALITY MEDICAL GRP.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:EMANUEL
Authorized Official - Last Name:PIERSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:323-730-0310
Mailing Address - Street 1:1828 S WESTERN AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-5808
Mailing Address - Country:US
Mailing Address - Phone:323-730-0310
Mailing Address - Fax:323-735-2743
Practice Address - Street 1:1828 S WESTERN AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5808
Practice Address - Country:US
Practice Address - Phone:323-730-0310
Practice Address - Fax:323-735-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53815174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063272Medicaid
CAGR0063270Medicaid
CAG53815OtherPROVIDER MEDICAL LICENSE
CAGR0063272Medicaid
CAGR0063270Medicaid
CAW13240Medicare ID - Type Unspecified