=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811146046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILBERT D CALLIS MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2008
-----------------------------------------------------
Last Update Date | 09/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 866 N VERMONT AVE 4
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-3587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-667-1008
-----------------------------------------------------
Fax | 323-667-1141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 866 N VERMONT AVE 4
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-3587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-667-1008
-----------------------------------------------------
Fax | 323-667-1141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. GILBERT D CALLIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 323-667-1008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | C24147
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------