Healthcare Provider Details

I. General information

NPI: 1962507103
Provider Name (Legal Business Name): OTOSURGICAL GROUP MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E SUITE 1700
LOS ANGELES CA
90067-2001
US

IV. Provider business mailing address

2080 CENTURY PARK E SUITE 1700
LOS ANGELES CA
90067-2001
US

V. Phone/Fax

Practice location:
  • Phone: 310-201-0728
  • Fax: 310-201-9665
Mailing address:
  • Phone: 310-201-0728
  • Fax: 310-201-9665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ALMA R. ORDAZ
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 310-201-0728