Healthcare Provider Details

I. General information

NPI: 1003225434
Provider Name (Legal Business Name): DIANA ZAGALSKAYA MD A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14111 VAN NESS AVE
GARDENA CA
90249-2950
US

IV. Provider business mailing address

14111 VAN NESS AVE
GARDENA CA
90249-2950
US

V. Phone/Fax

Practice location:
  • Phone: 323-449-4052
  • Fax:
Mailing address:
  • Phone: 323-449-4052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106875
License Number StateCA

VIII. Authorized Official

Name: DIANA ZAGALSKAYA
Title or Position: PRESIDENT
Credential: MD
Phone: 323-449-4052