Provider Demographics
NPI:1548216674
Name:FLAGG, GWENERVERE LOUISE (MD)
Entity Type:Individual
Prefix:MS
First Name:GWENERVERE
Middle Name:LOUISE
Last Name:FLAGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:FLAGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 91177
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-1177
Mailing Address - Country:US
Mailing Address - Phone:323-234-9595
Mailing Address - Fax:323-234-9588
Practice Address - Street 1:231 W VERNON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2700
Practice Address - Country:US
Practice Address - Phone:323-234-9595
Practice Address - Fax:323-234-9588
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42472204F00000X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G424720Medicaid
CAB57132Medicare UPIN
CAG42472Medicare ID - Type Unspecified