Provider Demographics
NPI:1932184223
Name:MADISON PARK FAMILY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MADISON PARK FAMILY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANORGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-944-9344
Mailing Address - Street 1:1970 SO PROSPECT AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:310-944-9344
Mailing Address - Fax:310-944-9390
Practice Address - Street 1:1970 SO PROSPECT AVE
Practice Address - Street 2:STE 3
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277
Practice Address - Country:US
Practice Address - Phone:310-944-9344
Practice Address - Fax:310-944-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13994OtherGROUP M CARE #
CAW13994Medicare PIN
W13994OtherGROUP M CARE #