Provider Demographics
NPI:1023482007
Name:DZEBOLO MD GROUP INC
Entity type:Organization
Organization Name:DZEBOLO MD GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:N
Authorized Official - Last Name:DZEBOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-484-3994
Mailing Address - Street 1:1100 RIDGESIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-3731
Mailing Address - Country:US
Mailing Address - Phone:626-281-6442
Mailing Address - Fax:888-302-2447
Practice Address - Street 1:2105 BEVERLY BLVD STE 111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2252
Practice Address - Country:US
Practice Address - Phone:213-484-3994
Practice Address - Fax:213-484-8795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6036396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46671Medicare UPIN