Healthcare Provider Details

I. General information

NPI: 1104980143
Provider Name (Legal Business Name): DE PALMA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W WILSON AVE
GLENDALE CA
91203-2409
US

IV. Provider business mailing address

1560 E CHEVY CHASE DR STE 435
GLENDALE CA
91206-4151
US

V. Phone/Fax

Practice location:
  • Phone: 818-500-8736
  • Fax: 818-500-7214
Mailing address:
  • Phone: 818-956-5357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG9647
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN R DE PALMA
Title or Position: C.E.O.
Credential: M.D.
Phone: 818-500-8736