Provider Demographics
NPI:1356872667
Name:AG INFECTIOUS DISEASES, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:AG INFECTIOUS DISEASES, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ARIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-256-6682
Mailing Address - Street 1:11301 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 121-435
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11301 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 121-435
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1653
Practice Address - Country:US
Practice Address - Phone:424-256-6682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68156282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A681560OtherMEDI-CAL PPIN
CAH94983Medicare UPIN
CAWA68156AMedicare PIN