Provider Demographics
NPI:1497055651
Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5720
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:
Practice Address - Street 1:9922 WALKER ST
Practice Address - Street 2:SUITE E
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-3097
Practice Address - Country:US
Practice Address - Phone:714-826-9810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16343Medicare PIN