Provider Demographics
NPI:1639924319
Name:CENTRAL MEDICAL GROUP
Entity type:Organization
Organization Name:CENTRAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:DZEBOLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:747-215-6350
Mailing Address - Street 1:710 S CENTRAL AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-4641
Mailing Address - Country:US
Mailing Address - Phone:747-215-6350
Mailing Address - Fax:747-215-6242
Practice Address - Street 1:710 S CENTRAL AVE STE 310
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-4641
Practice Address - Country:US
Practice Address - Phone:747-215-6350
Practice Address - Fax:747-215-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty