Provider Demographics
NPI:1013048461
Name:GASTROENTEROLOGY DIAGNOSTIC CENTER MEDICAL GROUP, A PROFESSIONAL
Entity type:Organization
Organization Name:GASTROENTEROLOGY DIAGNOSTIC CENTER MEDICAL GROUP, A PROFESSIONAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-872-6261
Mailing Address - Street 1:880 S ATLANTIC BLVD
Mailing Address - Street 2:#G 10
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4700
Mailing Address - Country:US
Mailing Address - Phone:626-872-6261
Mailing Address - Fax:626-872-1948
Practice Address - Street 1:880 S ATLANTIC BLVD
Practice Address - Street 2:SUITE G 10
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4700
Practice Address - Country:US
Practice Address - Phone:626-872-6261
Practice Address - Fax:626-872-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01185FMedicaid
CAS051186Medicare PIN