Provider Demographics
NPI:1023151040
Name:WHITTIER FETTERLY MEDICAL CLINIC INC.
Entity type:Organization
Organization Name:WHITTIER FETTERLY MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-269-4060
Mailing Address - Street 1:4762 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-3026
Mailing Address - Country:US
Mailing Address - Phone:323-269-4060
Mailing Address - Fax:323-269-5284
Practice Address - Street 1:4762 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3026
Practice Address - Country:US
Practice Address - Phone:323-269-4060
Practice Address - Fax:323-269-5284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90483208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A400700Medicaid
CAA90483OtherCA MED BD
CA00A400700Medicaid
CAW10194Medicare PIN