Provider Demographics
NPI:1609846955
Name:DE VIRGILIO, CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:DE VIRGILIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21840 NORMANDIE AVE
Mailing Address - Street 2:STE. 700
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2047
Mailing Address - Country:US
Mailing Address - Phone:310-222-5101
Mailing Address - Fax:310-320-5463
Practice Address - Street 1:21840 NORMANDIE AVE
Practice Address - Street 2:STE. 700
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2047
Practice Address - Country:US
Practice Address - Phone:310-222-5101
Practice Address - Fax:310-320-5463
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG625252086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G25250Medicaid
CAWG6225EMedicare ID - Type UnspecifiedPPIN
CAWG62525FMedicare ID - Type UnspecifiedPPIN
CA00G25250Medicaid
CAF44819Medicare UPIN