Provider Demographics
NPI:1033227970
Name:TARZANA PEDIATRIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:TARZANA PEDIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-345-7792
Mailing Address - Street 1:18370 BURBANK BLVD
Mailing Address - Street 2:SUITE #204
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2851
Mailing Address - Country:US
Mailing Address - Phone:818-345-7792
Mailing Address - Fax:818-345-9052
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:SUITE #204
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2851
Practice Address - Country:US
Practice Address - Phone:818-345-7792
Practice Address - Fax:818-345-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16804207RE0101X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG16804OtherSTATE LICENSE
CAGR0002970Medicaid
CAG16804OtherSTATE LICENSE