Provider Demographics
NPI:1487821757
Name:B. ROBERT BAMSHAD, M.D., INC.
Entity Type:Organization
Organization Name:B. ROBERT BAMSHAD, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BAMSHAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-854-0777
Mailing Address - Street 1:8635 W 3RD ST
Mailing Address - Street 2:SUITE 765W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-854-0777
Mailing Address - Fax:310-289-5198
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:SUITE 765W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-854-0777
Practice Address - Fax:310-289-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81239208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G812391Medicaid
CAG81239Medicare PIN
CAG79347Medicare UPIN