Provider Demographics
NPI:1053331595
Name:FOZAILOFF, ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:FOZAILOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77790
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0126
Mailing Address - Country:US
Mailing Address - Phone:951-278-5590
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:18370 BURBANK BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2804
Practice Address - Country:US
Practice Address - Phone:818-334-5750
Practice Address - Fax:951-272-9924
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76164207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A761640OtherBLUE SHILELD
CA00A761640Medicaid
CAA76164OtherLICENSE
CAA76164OtherLICENSE
H15088Medicare UPIN
CAH15088Medicare UPIN