Healthcare Provider Details

I. General information

NPI: 1326459256
Provider Name (Legal Business Name): MAGED BASILIOS, MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 E SLAUSON AVE SUITE E
MAYWOOD CA
90270-4955
US

IV. Provider business mailing address

4505 E SLAUSON AVE SUITE E
MAYWOOD CA
90270-4955
US

V. Phone/Fax

Practice location:
  • Phone: 323-771-0080
  • Fax: 323-771-0090
Mailing address:
  • Phone: 323-771-0080
  • Fax: 323-771-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA061990
License Number StateCA

VIII. Authorized Official

Name: MAGED BASILIOS
Title or Position: PRESIDENT
Credential: MD
Phone: 323-771-0080