Provider Demographics
NPI:1821081647
Name:FRIENDLY OB GYN MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FRIENDLY OB GYN MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-485-9133
Mailing Address - Street 1:12810 HEACOCK ST STE B105
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3171
Mailing Address - Country:US
Mailing Address - Phone:951-485-9133
Mailing Address - Fax:
Practice Address - Street 1:12810 HEACOCK ST STE B105
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3171
Practice Address - Country:US
Practice Address - Phone:951-485-9133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
G71778207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0089982Medicaid
CAGR0089980Medicaid
CAGR0089981Medicaid
F40047Medicare UPIN
CAGR0089980Medicaid