=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568822690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIRECT CARE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2016
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 W OLYMPIC BLVD STE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-4667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-756-1317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11900 AVALON BLVD STE 100
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90061-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-756-1317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JACK AZAD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-756-1317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A54433
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | A54433
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------