Basic Information
Provider Information | |||||||||
NPI: | 1568648780 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITRUS OBSTETRICS &GYNECOLOGY MEDICAL ASSOCIATES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CARLOS BEHARIE MD | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1433 W MERCED AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | WEST COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917903402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263378000 | ||||||||
FaxNumber: | 6263371145 | ||||||||
Practice Location | |||||||||
Address1: | 1433 W MERCED AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | WEST COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917903402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263378000 | ||||||||
FaxNumber: | 6263371145 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2008 | ||||||||
LastUpdateDate: | 08/01/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEHARIE | ||||||||
AuthorizedOfficialFirstName: | CARLOS | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6263378000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G46446 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 00G464460 | 05 | CA |   | MEDICAID |