Provider Demographics
NPI:1568649226
Name:UPTIMUM MEDICAL GROUP AND IPA INC
Entity Type:Organization
Organization Name:UPTIMUM MEDICAL GROUP AND IPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUKEMI
Authorized Official - Middle Name:ADERONKE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-644-8400
Mailing Address - Street 1:15342 HAWTHORNE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2181
Mailing Address - Country:US
Mailing Address - Phone:310-644-8400
Mailing Address - Fax:310-644-8424
Practice Address - Street 1:2220 W MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2514
Practice Address - Country:US
Practice Address - Phone:310-644-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8831128Medicaid
CAE81628Medicare UPIN
CAA48240Medicare PIN