Provider Demographics
NPI:1104849959
Name:BHOLAT, MICHELLE A (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:BHOLAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W. CENTURY BLVD
Mailing Address - Street 2:#400
Mailing Address - City:LOS ANGELS
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5655
Mailing Address - Country:US
Mailing Address - Phone:310-319-4728
Mailing Address - Fax:310-393-5659
Practice Address - Street 1:1920 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3414
Practice Address - Country:US
Practice Address - Phone:310-319-4700
Practice Address - Fax:310-393-5659
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G777720Medicaid
CAG75308Medicare UPIN
CA00G777720Medicaid
CAWG77772CMedicare PIN