Provider Demographics
NPI:1518996313
Name:CONSULTORIO MEDICO LATINO MEDICAL CENTER
Entity Type:Organization
Organization Name:CONSULTORIO MEDICO LATINO MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BEHROOZ
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:YAGOOBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-634-1000
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-0829
Mailing Address - Country:US
Mailing Address - Phone:562-634-1000
Mailing Address - Fax:562-634-3048
Practice Address - Street 1:15730 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-4333
Practice Address - Country:US
Practice Address - Phone:562-634-1000
Practice Address - Fax:562-634-3048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48328207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0108328OtherPIN
CAGR0067270Medicaid
CA0108328OtherPIN
CAGR0067270Medicaid
CAF18531Medicare UPIN