| 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_phone_number | provider_address_latitude | provider_address_longitude | mssa_id | tract_id |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1245548932 | 1245548932 | 1 | 2 | Zahedy-Kapusta, Sepideh Md | 5-Apr-13 | 26 | PHYSICIANS | A00099099 | 1 | General Practice | 0 | In state provider | 30 | Orange | None | 2094 W La Habra Blvd | None | La Habra | CA | 90631-0012 | (562) 696-1001 | 33.931848 | -117.96884 | 116k | 11.02 |
| 1679626170 | 1679626170 | 1 | 1 | Zacoalco Medical Grp Inc | 7-May-08 | 22 | PHYSICIANS GROUP | FNP002483 | 8 | Family Practice | 0 | In state provider | 15 | Kern | None | 5901 Niles St | None | Bakersfield | CA | 93306-4780 | (661) 363-7232 | 35.375942 | -118.936475 | 66b | 11.02 |
| 1750442836 | 1750442836 | 1 | 2 | Zacoalco Medical Grp Inc | 25-Nov-97 | 22 | PHYSICIANS GROUP | FNP024838 | 1 | General Practice | 0 | In state provider | 19 | Los Angeles | None | 1414 E Florence Ave | None | Los Angeles | CA | 90001-1937 | (323) 588-1383 | 33.974773 | -118.249384 | 78.2mmm | 5329 |