Healthcare Provider Details

I. General information

NPI: 1508840232
Provider Name (Legal Business Name): PASADENA COLON & RECTAL MED GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N MADISON AVE STE 410
PASADENA CA
91101-2035
US

IV. Provider business mailing address

65 N MADISON AVE STE 410
PASADENA CA
91101-2035
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-4261
  • Fax: 626-795-1506
Mailing address:
  • Phone: 626-795-4261
  • Fax: 626-795-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA029395
License Number StateCA

VIII. Authorized Official

Name: DR. LUIS WM MARTINEZ
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 626-795-4261