Provider Demographics
NPI:1598984288
Name:AMAVI A PROFESSIONAL MEDICAL
Entity Type:Organization
Organization Name:AMAVI A PROFESSIONAL MEDICAL
Other - Org Name:GUADALAJARA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:PEDROZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-263-3861
Mailing Address - Street 1:2705 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1441
Mailing Address - Country:US
Mailing Address - Phone:323-263-3861
Mailing Address - Fax:323-262-7132
Practice Address - Street 1:2705 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1441
Practice Address - Country:US
Practice Address - Phone:323-263-3861
Practice Address - Fax:323-262-7132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RS0012X
CAA51722261QF0050X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ43635ZOtherGROUP NUMBER