Healthcare Provider Details

I. General information

NPI: 1598893455
Provider Name (Legal Business Name): IMPERIAL PRIMARY CARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15625 IMPERIAL HWY
LA MIRADA CA
90638
US

IV. Provider business mailing address

15034 IMPERIAL HWY
LA MIRADA CA
90638-1301
US

V. Phone/Fax

Practice location:
  • Phone: 562-902-3000
  • Fax: 562-902-9563
Mailing address:
  • Phone: 562-902-3000
  • Fax: 562-902-9563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG32190
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA61645
License Number StateCA

VIII. Authorized Official

Name: JAMSHID MALEKI
Title or Position: PRESIDENT
Credential: MD
Phone: 562-902-3000