Provider Demographics
NPI:1710008578
Name:LA MULTISPECIALTY MEDICAL GROUP
Entity Type:Organization
Organization Name:LA MULTISPECIALTY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-383-4000
Mailing Address - Street 1:3663 W 6TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3049
Mailing Address - Country:US
Mailing Address - Phone:213-383-4000
Mailing Address - Fax:213-427-5588
Practice Address - Street 1:3663 W 6TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3049
Practice Address - Country:US
Practice Address - Phone:213-383-4000
Practice Address - Fax:213-427-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty