Healthcare Provider Details

I. General information

NPI: 1255586905
Provider Name (Legal Business Name): GARY L ZAGELBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 WILSHIRE BLVD SUITE 1504
LOS ANGELES CA
90048-5801
US

IV. Provider business mailing address

6200 WILSHIRE BLVD SUITE 1504
LOS ANGELES CA
90048-5801
US

V. Phone/Fax

Practice location:
  • Phone: 323-857-1323
  • Fax: 323-857-7089
Mailing address:
  • Phone: 323-857-1323
  • Fax: 323-857-7089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG36630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: