Provider Demographics
NPI:1750683306
Name:DECIO M RANGEL MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DECIO M RANGEL MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DECIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:RANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-7454
Mailing Address - Street 1:2001 SANTA MONICA BLVD STE 470W
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2192
Mailing Address - Country:US
Mailing Address - Phone:310-828-7454
Mailing Address - Fax:310-828-6362
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 470W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2192
Practice Address - Country:US
Practice Address - Phone:310-828-7454
Practice Address - Fax:310-828-6362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25197208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB50006Medicare UPIN