Healthcare Provider Details

I. General information

NPI: 1962912246
Provider Name (Legal Business Name): BIOGENX MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S GLENDORA AVE STE B
GLENDORA CA
91740-6815
US

IV. Provider business mailing address

620 S GLENDORA AVE STE B
GLENDORA CA
91740-6815
US

V. Phone/Fax

Practice location:
  • Phone: 818-836-2475
  • Fax: 310-943-1475
Mailing address:
  • Phone: 818-836-2475
  • Fax: 310-943-1475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberG77666
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierG77666
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCALIFORNIA MEDICAL LICENSE

VIII. Authorized Official

Name: DR. CHRISTOPHER A OTIKO
Title or Position: MANAGER
Credential: DPM
Phone: 818-836-2475