Provider Demographics
NPI:1861673246
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF OTOLARYNGOLOGY
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF OTOLARYNGOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5016
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-6453
Mailing Address - Fax:559-353-6457
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:SE18
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-6453
Practice Address - Fax:559-353-6457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR007868JMedicaid
CA1013968296OtherSMG GENERAL GROUP NPI NUMBER
CAGR007868JMedicaid