Provider Demographics
NPI:1881165546
Name:EOLB MEDICAL GROUP INC
Entity type:Organization
Organization Name:EOLB MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTROVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:818-960-5334
Mailing Address - Street 1:18180 ANDREA CIR N UNIT 5
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1107
Mailing Address - Country:US
Mailing Address - Phone:818-960-5334
Mailing Address - Fax:
Practice Address - Street 1:16927 VANOWEN ST STE 4
Practice Address - Street 2:
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-4582
Practice Address - Country:US
Practice Address - Phone:818-483-4717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty