Provider Demographics
NPI:1639218340
Name:QUISIDO, EARLA E (MD)
Entity Type:Individual
Prefix:
First Name:EARLA
Middle Name:E
Last Name:QUISIDO
Suffix:
Gender:F
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:PO BOX 9723
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91226-0723
Mailing Address - Country:US
Mailing Address - Phone:213-483-8300
Mailing Address - Fax:213-483-8088
Practice Address - Street 1:2105 BEVERLY BLVD STE 213
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2272
Practice Address - Country:US
Practice Address - Phone:213-483-8300
Practice Address - Fax:213-483-8088
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA481003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A481003Medicaid
CAE73851Medicare UPIN