Provider Demographics
NPI:1528586096
Name:ENDEAVOR MEDICAL GROUP
Entity Type:Organization
Organization Name:ENDEAVOR MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMUR
Authorized Official - Middle Name:RUSLANOVICH
Authorized Official - Last Name:POGODIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-812-9506
Mailing Address - Street 1:20246 SITACOY STREET
Mailing Address - Street 2:STE# 201
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306
Mailing Address - Country:US
Mailing Address - Phone:818-812-9506
Mailing Address - Fax:818-812-9508
Practice Address - Street 1:20246 SATICOY ST STE 201
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:CA
Practice Address - Zip Code:91306-4433
Practice Address - Country:US
Practice Address - Phone:818-812-9506
Practice Address - Fax:818-812-9508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA133706261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care