Provider Demographics
NPI:1689849481
Name:LADERA MEDICAL PRACTICE INC
Entity Type:Organization
Organization Name:LADERA MEDICAL PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEEDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-545-9288
Mailing Address - Street 1:5141 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1853
Mailing Address - Country:US
Mailing Address - Phone:323-545-9288
Mailing Address - Fax:323-545-9287
Practice Address - Street 1:5141 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1853
Practice Address - Country:US
Practice Address - Phone:323-545-9288
Practice Address - Fax:323-545-9287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X, 2086S0127X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A630290Medicaid
CA00G459770Medicaid
CAA45977Medicare UPIN
CA00G459770Medicaid
CA1689607293Medicare PIN
CA1306862701Medicare PIN