Provider Demographics
NPI:1043366164
Name:VISTA MEDICAL PARTNERS A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:VISTA MEDICAL PARTNERS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-288-5933
Mailing Address - Street 1:2105 BEVERLY BLVD STE 231
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2287
Mailing Address - Country:US
Mailing Address - Phone:310-288-5933
Mailing Address - Fax:866-683-4556
Practice Address - Street 1:2105 BEVERLY BLVD STE 231
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2287
Practice Address - Country:US
Practice Address - Phone:310-288-5933
Practice Address - Fax:866-683-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G730431Medicaid
CA00G730431Medicaid