Provider Demographics
NPI:1346377736
Name:AFFLACK, PHABILLIA (PHYSICIAN)
Entity Type:Individual
Prefix:DR
First Name:PHABILLIA
Middle Name:
Last Name:AFFLACK
Suffix:
Gender:F
Credentials:PHYSICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11870 SANTA MONICA BLVD # 106743
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2276
Mailing Address - Country:US
Mailing Address - Phone:323-283-9877
Mailing Address - Fax:
Practice Address - Street 1:329 N WETHERLY DR STE 209
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1675
Practice Address - Country:US
Practice Address - Phone:323-760-7277
Practice Address - Fax:323-978-6094
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55443207V00000X
NY233559207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01806239Medicaid
NY01806239Medicaid
NYI51599Medicare UPIN