Healthcare Provider Details

I. General information

NPI: 1295019487
Provider Name (Legal Business Name): URBAN MED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W 11TH ST
LOS ANGELES CA
90015-2102
US

IV. Provider business mailing address

408 W 11TH ST
LOS ANGELES CA
90015-2102
US

V. Phone/Fax

Practice location:
  • Phone: 213-406-8055
  • Fax:
Mailing address:
  • Phone: 213-406-8055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A8154
License Number StateCA

VIII. Authorized Official

Name: DR. STACEY NAITO
Title or Position: PHYSICIAN
Credential: D.O
Phone: 213-406-8055