Provider Demographics
NPI:1265623524
Name:IMPERIAL VALLEY ENDOCRINE MEDICAL CORPORATION
Entity type:Organization
Organization Name:IMPERIAL VALLEY ENDOCRINE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KRUTZIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-344-1881
Mailing Address - Street 1:528 G ST
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-2411
Mailing Address - Country:US
Mailing Address - Phone:760-344-6355
Mailing Address - Fax:760-344-6321
Practice Address - Street 1:528 G ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2411
Practice Address - Country:US
Practice Address - Phone:760-344-6355
Practice Address - Fax:760-344-6921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70812207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A708120Medicaid
CAW21299Medicare PIN