1013569565 NPI number — DR. PHILIP AARON ETTEDGUI PHARMD

Table of content: DR. PHILIP AARON ETTEDGUI PHARMD (NPI 1013569565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013569565 NPI number — DR. PHILIP AARON ETTEDGUI PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETTEDGUI
Provider First Name:
PHILIP
Provider Middle Name:
AARON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013569565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12137 TIARA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY VILLAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91607-1118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-259-5375
Provider Business Mailing Address Fax Number:
818-881-2996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5060 W SUNSET BLVD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90027-5872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-667-1111
Provider Business Practice Location Address Fax Number:
323-667-1131
Provider Enumeration Date:
07/15/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  49611 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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