MEDICARE: DEL PUEBLO MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A859840	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689779977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEL PUEBLO MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	1505 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-4544
Country	:	US
Telephone Number	:	213-387-8515
Fax Number	:	213-387-0797

Provider Business Practice Location Address
First Line	:	2721 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2609
Country	:	US
Telephone Number	:	323-223-0916
Fax Number	:	323-223-8411

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. RENE LOPEZ
Credential	:
Telephone Number	:	213-272-7186

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	08/22/2020

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Directions to “DEL PUEBLO MEDICAL CLINIC ” Practice Location

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