Healthcare Provider Details

I. General information

NPI: 1023482007
Provider Name (Legal Business Name): DZEBOLO MD GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 BEVERLY BLVD STE 111
LOS ANGELES CA
90057-2252
US

IV. Provider business mailing address

1100 RIDGESIDE DR
MONTEREY PARK CA
91754-3731
US

V. Phone/Fax

Practice location:
  • Phone: 213-484-3994
  • Fax: 213-484-8795
Mailing address:
  • Phone: 626-281-6442
  • Fax: 888-302-2447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6036396
License Number StateCA

VIII. Authorized Official

Name: NICHOLAS N DZEBOLO
Title or Position: OWNER
Credential: MD
Phone: 213-484-3994