Healthcare Provider Details

I. General information

NPI: 1386025773
Provider Name (Legal Business Name): L A STAR MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10132 CALIFORNIA AVE
SOUTH GATE CA
90280-6008
US

IV. Provider business mailing address

10132 CALIFORNIA AVE
SOUTH GATE CA
90280-6008
US

V. Phone/Fax

Practice location:
  • Phone: 323-566-4411
  • Fax: 323-566-0390
Mailing address:
  • Phone: 323-566-4411
  • Fax: 323-566-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56273
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA56273
License Number StateCA

VIII. Authorized Official

Name: EMILE SHENOUDA
Title or Position: PRESIDENT
Credential: MD
Phone: 323-566-4411