Healthcare Provider Details

I. General information

NPI: 1720453574
Provider Name (Legal Business Name): SAM GHALILI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 S SAN PEDRO ST
LOS ANGELES CA
90011-1125
US

IV. Provider business mailing address

2101 S SAN PEDRO ST
LOS ANGELES CA
90011-1125
US

V. Phone/Fax

Practice location:
  • Phone: 213-845-8766
  • Fax: 213-745-8704
Mailing address:
  • Phone: 213-845-8766
  • Fax: 213-745-8704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA88734
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. SAM GHALILI
Title or Position: OWNER
Credential: M.D.
Phone: 213-749-7110