Healthcare Provider Details

I. General information

NPI: 1386748614
Provider Name (Legal Business Name): PID ASSOCIATES MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

1536 W 25TH ST PMB 163
SAN PEDRO CA
90732-4415
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-8590
  • Fax: 562-933-8093
Mailing address:
  • Phone: 562-933-8590
  • Fax: 562-933-8093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberA40896
License Number StateCA

VIII. Authorized Official

Name: DR. AUDRA DEVEIKIS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 562-933-8590