Provider Demographics
NPI:1689779977
Name:DEL PUEBLO MEDICAL CLINIC
Entity Type:Organization
Organization Name:DEL PUEBLO MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-272-7186
Mailing Address - Street 1:1505 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-4544
Mailing Address - Country:US
Mailing Address - Phone:213-387-8515
Mailing Address - Fax:213-387-0797
Practice Address - Street 1:2721 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2609
Practice Address - Country:US
Practice Address - Phone:323-223-0916
Practice Address - Fax:323-223-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA859840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA859840Medicaid
CAA859840Medicaid