Provider Demographics
NPI: | 1114951167 |
---|---|
Name: | KEROLES, NANCY S (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | NANCY |
Middle Name: | S |
Last Name: | KEROLES |
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: | 1516 COTNER AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | LOS ANGELES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90025-3303 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-445-2951 |
Mailing Address - Fax: | 310-479-1459 |
Practice Address - Street 1: | 1516 COTNER AVE |
Practice Address - Street 2: | |
Practice Address - City: | LOS ANGELES |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90025-3303 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-445-2951 |
Practice Address - Fax: | 310-479-1459 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-10 |
Last Update Date: | 2015-02-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A64710 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00A647100 | Other | BLUE SHIELD |
CA | 00A647100 | Medicaid | |
CA | WA64710C | Medicare PIN | |
CA | WA64710B | Medicare PIN | |
CA | 00A647100 | Other | BLUE SHIELD |
CA | 00A647100 | Medicaid | |
CA | WA64710A | Medicare PIN |