Provider Demographics
NPI:1548200637
Name:GRITZ, RICHARD M (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:GRITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 1261
Mailing Address - Street 2:1801 W. OLYMPIC BOULEVARD
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-1261
Mailing Address - Country:US
Mailing Address - Phone:877-406-2916
Mailing Address - Fax:800-656-0592
Practice Address - Street 1:18344 CLARK STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-881-9811
Practice Address - Fax:818-881-1638
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG216552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G216550Medicaid
CA00G216550OtherBLUE SHIELD
CAWG21655JMedicare PIN
CAWG21655KMedicare PIN
CAWG21655FMedicare PIN
A90719Medicare UPIN
CA00G216550OtherBLUE SHIELD