Healthcare Provider Details

I. General information

NPI: 1306050463
Provider Name (Legal Business Name): SAN GABRIEL PHYSICIANS SPECIALTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 DALY STREET
LOS ANGELES CA
90031
US

IV. Provider business mailing address

2411 DALY STREET
LOS ANGELES CA
90031
US

V. Phone/Fax

Practice location:
  • Phone: 323-223-9931
  • Fax: 323-223-1229
Mailing address:
  • Phone: 323-223-9931
  • Fax: 323-223-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA31083
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA33207
License Number StateCA

VIII. Authorized Official

Name: DR. MARIA EUGENIA KHALATIAN
Title or Position: PEDIATRICIAN
Credential: M.D.
Phone: 323-223-9931