Provider Demographics
NPI:1932295474
Name:NORTHWEST VALLEY FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:NORTHWEST VALLEY FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P./TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:BARTE
Authorized Official - Last Name:MASONGSONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-727-1974
Mailing Address - Street 1:19182 DUNURE PLACE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326
Mailing Address - Country:US
Mailing Address - Phone:818-368-2859
Mailing Address - Fax:818-727-7726
Practice Address - Street 1:21119 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311
Practice Address - Country:US
Practice Address - Phone:818-727-1974
Practice Address - Fax:818-727-7726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101261Medicaid
CAGR0101260Medicaid
CAGR0101261Medicaid
I01785Medicare UPIN
W17326Medicare ID - Type Unspecified