Basic Information
| Provider Information | |||||||||
| NPI: | 1962412643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | A DE LA PENA M D A MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | A. DE LA PENA MD, AMG, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2446 W WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906403041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237285500 | ||||||||
| FaxNumber: | 3237284408 | ||||||||
| Practice Location | |||||||||
| Address1: | 139 S ALVARADO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900572201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134840170 | ||||||||
| FaxNumber: | 2134840246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | DE LA PENA | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3237285500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.