Provider Demographics
NPI:1467527382
Name:BLEAKLEY, DENNIS WALTER (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:WALTER
Last Name:BLEAKLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 JILLSON ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-1482
Mailing Address - Country:US
Mailing Address - Phone:562-867-7999
Mailing Address - Fax:
Practice Address - Street 1:1670 E 120TH ST BLDG 14
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3026
Practice Address - Country:US
Practice Address - Phone:562-867-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24509207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG24509COtherPPIN
CAA42284Medicare UPIN