Healthcare Provider Details

I. General information

NPI: 1811385230
Provider Name (Legal Business Name): LA JOLLA MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 WILSHIRE BLVD SUITE 509
LOS ANGELES CA
90048-5201
US

IV. Provider business mailing address

6221 WILSHIRE BLVD SUITE 509
LOS ANGELES CA
90048-5201
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-6431
  • Fax: 323-653-3895
Mailing address:
  • Phone: 323-653-6431
  • Fax: 323-653-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA103993
License Number StateCA

VIII. Authorized Official

Name: MASHA J LIVHITS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-653-6431