Provider Demographics
NPI:1811385230
Name:LA JOLLA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LA JOLLA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MASHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIVHITS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-653-6431
Mailing Address - Street 1:6221 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 509
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5201
Mailing Address - Country:US
Mailing Address - Phone:323-653-6431
Mailing Address - Fax:323-653-3895
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:SUITE 509
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-653-6431
Practice Address - Fax:323-653-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103993207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty