Healthcare Provider Details

I. General information

NPI: 1558542076
Provider Name (Legal Business Name): GLORIA DE OLARTE M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N.MADISON AVENUE SUITE 406
PASADENA CA
91101
US

IV. Provider business mailing address

65 N.MADISON AVENUE SUITE 406
PASADENA CA
91101
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-7965
  • Fax:
Mailing address:
  • Phone: 626-577-7965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA35537
License Number StateCA

VIII. Authorized Official

Name: DR. GLORIA DE OLARTE I
Title or Position: OWNER
Credential: DOCTOR
Phone: 626-577-7965