Provider Demographics
NPI:1891724993
Name:GHALILI MD INC, SAM (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:GHALILI MD INC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1125
Mailing Address - Country:US
Mailing Address - Phone:213-745-8766
Mailing Address - Fax:213-745-8704
Practice Address - Street 1:2101 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1125
Practice Address - Country:US
Practice Address - Phone:213-745-8766
Practice Address - Fax:213-745-8704
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88734261QU0200X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88734Medicaid
CAA88734Medicaid