Provider Demographics
NPI:1851709406
Name:NAGASAMUDRA S ASHOK MD INC
Entity Type:Organization
Organization Name:NAGASAMUDRA S ASHOK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAGASAMUDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ASHOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-515-8804
Mailing Address - Street 1:1520 N MOUNTAIN AVE BLDG F
Mailing Address - Street 2:SUITE 128
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-1128
Mailing Address - Country:US
Mailing Address - Phone:909-949-9299
Mailing Address - Fax:909-949-9029
Practice Address - Street 1:1520 N MOUNTAIN AVE BLDG F
Practice Address - Street 2:SUITE 128
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1128
Practice Address - Country:US
Practice Address - Phone:909-949-9299
Practice Address - Fax:909-949-9029
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NAGASAMUDRA S. ASHOK MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-28
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A415890Medicaid
CAWA41589Medicare PIN