MEDICARE: A DE LA PENA M D A MEDICAL GROUP 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	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1962412643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A DE LA PENA M D A MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	2446 W WHITTIER BLVD
Second Line	:
City	:	MONTEBELLO
State	:	CA
Zip	:	90640-3041
Country	:	US
Telephone Number	:	323-728-5500
Fax Number	:	323-728-4408

Provider Business Practice Location Address
First Line	:	139 S ALVARADO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2201
Country	:	US
Telephone Number	:	213-484-0170
Fax Number	:	213-484-0246

Authorized Official
Title or Position	:	OWNER
Name	:	ALBERT DE LA PENA
Credential	:	M.D.
Telephone Number	:	323-728-5500

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	02/25/2013

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