Provider Demographics
NPI:1952549040
Name:GEORGE T. COLOSIMO, M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:GEORGE T. COLOSIMO, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:T
Authorized Official - Last Name:COLOSIMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-837-5155
Mailing Address - Street 1:3831 HUGHES AVE
Mailing Address - Street 2:SUITE 608
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2751
Mailing Address - Country:US
Mailing Address - Phone:310-837-5155
Mailing Address - Fax:310-837-5274
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:SUITE 608
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-837-5155
Practice Address - Fax:310-837-5274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48286208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF63971Medicare UPIN