Provider Demographics
NPI:1710023718
Name:BRIAN H. ITAGAKI M.D., INC.
Entity Type:Organization
Organization Name:BRIAN H. ITAGAKI M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:HIRO
Authorized Official - Last Name:ITAGAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-484-7303
Mailing Address - Street 1:2200 W 3RD ST
Mailing Address - Street 2:120A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1932
Mailing Address - Country:US
Mailing Address - Phone:213-484-7303
Mailing Address - Fax:213-484-7399
Practice Address - Street 1:2200 W 3RD ST
Practice Address - Street 2:SUITE 120A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1932
Practice Address - Country:US
Practice Address - Phone:213-484-7303
Practice Address - Fax:213-484-7399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37936207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G379360Medicaid
CA006379360OtherBLUE SHIELD
CA155649300OtherDEPARTMENT OF LABOR
CA0004227410OtherAETNA
CAG37936OtherMEDICARE INDIVIDUAL PTAN
CA155649300OtherDEPARTMENT OF LABOR
CA00G379360Medicaid