Provider Demographics
NPI:1720257926
Name:MEDICAL & SURGICAL CLINIC OF NORWALK A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MEDICAL & SURGICAL CLINIC OF NORWALK A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANOUCHEHR
Authorized Official - Middle Name:
Authorized Official - Last Name:ESMAILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-868-5757
Mailing Address - Street 1:13132 STUDEBAKER RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2557
Mailing Address - Country:US
Mailing Address - Phone:562-868-5757
Mailing Address - Fax:562-863-9445
Practice Address - Street 1:13132 STUDEBAKER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2557
Practice Address - Country:US
Practice Address - Phone:562-868-5757
Practice Address - Fax:562-863-9445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A411330Medicaid
CA00A411330Medicaid