MEDICARE: PROSPECT MEDICAL GROUP AZ, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1366037152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSPECT MEDICAL GROUP AZ, INC.

Provider Business Mailing Address
First Line	:	3415 S SEPULVEDA BLVD FL 9
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6060
Country	:	US
Telephone Number	:	310-943-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3415 S SEPULVEDA BLVD FL 9
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6060
Country	:	US
Telephone Number	:	310-943-4500
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	ROBERT ELDERS
Credential	:
Telephone Number	:	310-943-4500

Provider Enumeration Date	:	03/04/2021
Last Update Date	:	03/04/2021

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