Provider Demographics
NPI:1144356627
Name:PEDRO DOMINGO-FORASTE M.D. INC.,
Entity type:Organization
Organization Name:PEDRO DOMINGO-FORASTE M.D. INC.,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGO-FORASTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-268-8511
Mailing Address - Street 1:2256 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-1243
Mailing Address - Country:US
Mailing Address - Phone:323-268-8511
Mailing Address - Fax:323-268-0717
Practice Address - Street 1:2256 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1243
Practice Address - Country:US
Practice Address - Phone:323-268-8511
Practice Address - Fax:323-268-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70430ZMedicaid
CAE93836Medicare UPIN
CAZZZ70430ZMedicaid