Healthcare Provider Details

I. General information

NPI: 1497293682
Provider Name (Legal Business Name): MDSM GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 490W
SANTA MONICA CA
90404-2127
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD STE 490W
SANTA MONICA CA
90404-2127
US

V. Phone/Fax

Practice location:
  • Phone: 323-459-1543
  • Fax:
Mailing address:
  • Phone: 323-459-1543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA111784
License Number StateCA

VIII. Authorized Official

Name: DARREN M BOYER
Title or Position: CEO
Credential: M.D.
Phone: 323-459-1543