Healthcare Provider Details

I. General information

NPI: 1457204380
Provider Name (Legal Business Name): MODERN CONCEPTS MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2026
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5836 E BEVERLY BLVD
LOS ANGELES CA
90022-2824
US

IV. Provider business mailing address

5836 E BEVERLY BLVD
LOS ANGELES CA
90022-2824
US

V. Phone/Fax

Practice location:
  • Phone: 323-726-0370
  • Fax: 323-726-0239
Mailing address:
  • Phone: 323-726-0370
  • Fax: 323-726-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GUSTAVO CALLEROS
Title or Position: DOCTOR
Credential:
Phone: 323-728-6070