Basic Information
Provider Information | |||||||||
NPI: | 1982857967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIH HEALTH PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PIH HEALTH PHYSICIANS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 1277 | ||||||||
Address2: |   | ||||||||
City: | WHITTIER | ||||||||
State: | CA | ||||||||
PostalCode: | 906091277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5627895401 | ||||||||
FaxNumber: | 5627895912 | ||||||||
Practice Location | |||||||||
Address1: | 12675 LA MIRADA BLVD | ||||||||
Address2: | SUITE 201, 300, 301, 401 | ||||||||
City: | LA MIRADA | ||||||||
State: | CA | ||||||||
PostalCode: | 906382200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629037339 | ||||||||
FaxNumber: | 5629448631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2008 | ||||||||
LastUpdateDate: | 07/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MIYAMOTO | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT , PHYSICIANS SERVICES | ||||||||
AuthorizedOfficialTelephone: | 5627895401 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 07/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 6529 | 01 | CA | LICENSE | OTHER |