Provider Demographics
NPI:1982618849
Name:A. DE LA PENA M D A MEDICAL GROUP INC
Entity type:Organization
Organization Name:A. DE LA PENA M D A MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA PENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-988-1111
Mailing Address - Street 1:2446 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3041
Mailing Address - Country:US
Mailing Address - Phone:323-728-5500
Mailing Address - Fax:323-728-4408
Practice Address - Street 1:7100 VAN NUYS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3063
Practice Address - Country:US
Practice Address - Phone:818-988-1111
Practice Address - Fax:818-988-1734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11196DMedicare ID - Type Unspecified
0610180005Medicare NSC