Basic Information
| Provider Information | |||||||||
| NPI: | 1801964705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REGALADO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 ZONAL AVE | ||||||||
| Address2: | IRD 124 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900339985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232263691 | ||||||||
| FaxNumber: | 3232265692 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 ZONAL AVE | ||||||||
| Address2: | IRD 124 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900339985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232263691 | ||||||||
| FaxNumber: | 3232265692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 12/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G48168 | CA | N | Other Service Providers | Specialist | 208000000X | G48168 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 165820 | 05 | CA | MEDICAID |