Provider Demographics
NPI:1598720641
Name:UNIVERSAL PRIMARY CARE
Entity Type:Organization
Organization Name:UNIVERSAL PRIMARY CARE
Other - Org Name:ENDOCRINOLOGY OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLADYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-265-2210
Mailing Address - Street 1:801 S CHEVY CHASE DR
Mailing Address - Street 2:102
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4431
Mailing Address - Country:US
Mailing Address - Phone:818-226-5224
Mailing Address - Fax:818-241-7708
Practice Address - Street 1:801 SOUTH CHEVY CHASE DR
Practice Address - Street 2:#102
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-226-5224
Practice Address - Fax:818-241-7708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059756Medicaid
CA=========OtherTAX IDENTIFICATION NUMBER
CAGR0059756Medicaid