Healthcare Provider Details

I. General information

NPI: 1457440497
Provider Name (Legal Business Name): ESTIANDAN'S MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 BEVERLY BLVD SUITE 100
LOS ANGELES CA
90057-2200
US

IV. Provider business mailing address

2115 BEVERLY BLVD SUITE 100
LOS ANGELES CA
90057-2200
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-6080
  • Fax: 213-483-6234
Mailing address:
  • Phone: 213-483-6080
  • Fax: 213-483-6234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA38326
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA38326
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA38326
License Number StateCA

VIII. Authorized Official

Name: DR. CARLOS P. ESTIANDAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-483-7315