Provider Demographics
NPI:1245450212
Name:GUADALAJARA MEDICAL CLINIC
Entity type:Organization
Organization Name:GUADALAJARA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:PEDROZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-263-3861
Mailing Address - Street 1:2705 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1441
Mailing Address - Country:US
Mailing Address - Phone:323-263-3861
Mailing Address - Fax:323-262-7132
Practice Address - Street 1:2705 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1441
Practice Address - Country:US
Practice Address - Phone:323-263-3861
Practice Address - Fax:323-262-7132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW432Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER