Provider Demographics
NPI:1083679377
Name:KANOFSKY, MYRON ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:ROSS
Last Name:KANOFSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W LA VETA AVE
Mailing Address - Street 2:SUITE 775
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4306
Mailing Address - Country:US
Mailing Address - Phone:714-954-0270
Mailing Address - Fax:714-954-0272
Practice Address - Street 1:1010 W LA VETA AVE
Practice Address - Street 2:SUITE 775
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4306
Practice Address - Country:US
Practice Address - Phone:714-954-0270
Practice Address - Fax:714-954-0272
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2012-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40010207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
33-0306480OtherCHAMPUS
CA00C400100Medicaid
CA00C400100Medicaid