MEDICARE: HAGOS HABTEZGHI, MD MEDICAL CORPORATION

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	261QP2300X	Primary Care Clinic/Center	00C415001	CA

General Provider Information

NPI Number	:	1811257363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAGOS HABTEZGHI, MD MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	9901 COMPTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-2850
Country	:	US
Telephone Number	:	323-835-8401
Fax Number	:	323-835-8405

Provider Business Practice Location Address
First Line	:	9901 COMPTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-2850
Country	:	US
Telephone Number	:	323-835-8401
Fax Number	:	323-835-8405

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. HAGOS HABTEZGHI
Credential	:	MD
Telephone Number	:	323-835-8401

Provider Enumeration Date	:	05/17/2012
Last Update Date	:	05/17/2012

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