Provider Demographics
NPI:1427557669
Name:UNIVERSITY FOOT & ANKLE INSTITUTE PODIACTRIC SURGICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY FOOT & ANKLE INSTITUTE PODIACTRIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARAVARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-828-0011
Mailing Address - Street 1:2121 WILSHIRE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5742
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:
Practice Address - Street 1:16311 VENTURA BLVD STE 1080
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4352
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY FOOT & ANKLE INSTITUTE PODIACTRIC SURGICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4186213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty