Provider Demographics
NPI:1528101029
Name:CLINICA POPULAR MEDICAL GROUP
Entity type:Organization
Organization Name:CLINICA POPULAR MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERDAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-381-7175
Mailing Address - Street 1:2410 W. 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LOAS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3904
Mailing Address - Country:US
Mailing Address - Phone:213-381-7175
Mailing Address - Fax:213-381-7028
Practice Address - Street 1:2410 W. 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3904
Practice Address - Country:US
Practice Address - Phone:213-381-7175
Practice Address - Fax:213-381-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207QA35536D207QA0000X
CA207RA35536D207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA35536DOtherRENDERING PROVIDER
CAWA35536DOtherRENDERING PROVIDER