Basic Information
| Provider Information | |||||||||
| NPI: | 1629060694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VARGA | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 50475 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264036200 | ||||||||
| FaxNumber: | 6264032968 | ||||||||
| Practice Location | |||||||||
| Address1: | 1017 S FAIR OAKS AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264036200 | ||||||||
| FaxNumber: | 6264032968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 04/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | G52859 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 2081P2900X | G52859 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | G52859 | 01 | CA | MEDICAL LICENSE | OTHER | 00G528590 | 05 | CA | MEDICAID |