Healthcare Provider Details

I. General information

NPI: 1619445640
Provider Name (Legal Business Name): SERPAH MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E STE 710
LOS ANGELES CA
90067-2010
US

IV. Provider business mailing address

2080 CENTURY PARK E STE 710
LOS ANGELES CA
90067-2010
US

V. Phone/Fax

Practice location:
  • Phone: 424-274-3211
  • Fax:
Mailing address:
  • Phone: 424-274-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN MATTHEW NELSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-883-8920