| provider_number | npi_provider_number | owner_number | service_location_number | provider_business_legal_name | enrollment_status_effective_date | provider_type_code | provider_type_code_desc | provider_license_number | provider_specialty_code | provider_specialty_code_desc | out_of_state_ind | out_of_state_ind_desc | provider_address_county_code | provider_address_county_desc | attention_line | provider_address_line1 | provider_address_line2 | provider_address_city | provider_address_state | provider_address_zip | provider_address_latitude | provider_address_longitude | mssa_id | tract_id |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1245548932 | 1245548932 | 1 | 2 | ZAHEDY-KAPUSTA, SEPIDEH MD | 01Mar2013 | 026 | PHYSICIANS | A00099099 | 01 | General Practice | 0 | In state provider | 30 | Orange | None | 2094 W LA HABRA BLVD | None | LA HABRA | CA | 906310012 | 33.931848 | -117.968840 | 116k | 11.02 |
| 1750442836 | 1750442836 | 1 | 2 | ZACOALCO MEDICAL GRP INC | 31Aug1996 | 022 | PHYSICIANS GROUP | FNP024838 | None | UNKNOWN | 0 | In state provider | 19 | Los Angeles | None | 1414 E FLORENCE AVE | None | LOS ANGELES | CA | 900011937 | 33.974773 | -118.249384 | 78.2mmm | 5329 |