Provider Demographics
NPI:1477980597
Name:GHOZLAND-LIPELES, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GHOZLAND-LIPELES, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LIPELES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-629-2447
Mailing Address - Street 1:9808 VENICE BLVD
Mailing Address - Street 2:PENTHOUSE
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2732
Mailing Address - Country:US
Mailing Address - Phone:310-629-2447
Mailing Address - Fax:310-306-5555
Practice Address - Street 1:9808 VENICE BLVD
Practice Address - Street 2:PENTHOUSE
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2732
Practice Address - Country:US
Practice Address - Phone:310-629-2447
Practice Address - Fax:310-306-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10501207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750375929Medicaid
CA1376794966Medicaid