Provider Demographics
NPI:1568822690
Name:DIRECT CARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DIRECT CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-756-1317
Mailing Address - Street 1:11900 AVALON BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2866
Mailing Address - Country:US
Mailing Address - Phone:323-756-1317
Mailing Address - Fax:
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:STE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-756-1317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54433207Q00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG17920Medicare UPIN