Provider Demographics
NPI:1144262817
Name:SAN GABRIEL VIP A CALIFORNIA LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:SAN GABRIEL VIP A CALIFORNIA LIMITED PARTNERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:KAISERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-813-9988
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91793-0635
Mailing Address - Country:US
Mailing Address - Phone:626-813-9988
Mailing Address - Fax:626-813-0075
Practice Address - Street 1:1115 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3940
Practice Address - Country:US
Practice Address - Phone:626-813-9988
Practice Address - Fax:626-813-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCBSOtherZZZ25286Z
CAGR0058270Medicaid
CACQ2233OtherMEDICARE RR
CAGR0058270Medicaid