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General NPI Number Information
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NPI Number | 1457477523
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Entity Type | Organization
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Legal Business Name | GARY M TEARSTON MD A MEDICAL CORP
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 03/11/2009
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Provider Practice Location Address
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Address Line | 2122 CENTURY PARK LN UNIT 207
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City | LOS ANGELES
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State | CA
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Zip | 90067-3304
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Country | US
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Telephone | 310-659-5502
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Fax | 310-659-7639
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Provider Business Mailing Address
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Address Line | PO BOX 18587
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City | BEVERLY HILLS
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State | CA
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Zip | 90209-4587
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Country | US
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Telephone | 310-659-5502
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Fax | 310-659-7639
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY M TEARSTON
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Credential | M.D.
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Telephone | 310-659-5502
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G15838
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License Number State | CA
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