Provider Demographics
NPI:1912136987
Name:WEST GASTROENTEROLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:WEST GASTROENTEROLOGY MEDICAL GROUP
Other - Org Name:WEST GASTROENTROLOGY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEBAMBO
Authorized Official - Middle Name:OLADELE
Authorized Official - Last Name:OJURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-674-0144
Mailing Address - Street 1:PO BOX 881840
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-3013
Mailing Address - Country:US
Mailing Address - Phone:310-674-0144
Mailing Address - Fax:310-674-1704
Practice Address - Street 1:25405 HANCOCK AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5982
Practice Address - Country:US
Practice Address - Phone:310-674-0144
Practice Address - Fax:310-674-1704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST GASTROENTEROLOGY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46336174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9516770125OtherTEL. NUMBER
CAW3492Medicare PIN