MEDICARE: SAN GABRIEL PEDIATRICS 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	261Q00000X	Clinic/Center	A53449	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962400028
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN GABRIEL PEDIATRICS MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	3450 W 43RD ST
Second Line	:	SUITE 107
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4943
Country	:	US
Telephone Number	:	323-290-2832
Fax Number	:	323-290-2836

Provider Business Practice Location Address
First Line	:	3450 W 43RD ST
Second Line	:	SUITE 107
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4943
Country	:	US
Telephone Number	:	323-290-2832
Fax Number	:	323-290-2836

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. MEZIA OGUGUA AZINGE-OBASI
Credential	:	M.D.
Telephone Number	:	323-290-2832

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	03/02/2010

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