Provider Demographics
NPI:1104617315
Name:ASUTA MEDICAL GROUP INC
Entity type:Organization
Organization Name:ASUTA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ELSAGAV
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-636-3869
Mailing Address - Street 1:14545 FRIAR ST STE 236
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-4719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14545 FRIAR ST STE 236
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-4719
Practice Address - Country:US
Practice Address - Phone:323-636-3869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service