Provider Demographics
NPI:1497948681
Name:BARRY S NEIDORF MD INC
Entity Type:Organization
Organization Name:BARRY S NEIDORF MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:SHERWIN
Authorized Official - Last Name:NEIDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-277-2771
Mailing Address - Street 1:2080 CENTURY PARK EAST
Mailing Address - Street 2:SUITE 1006
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067
Mailing Address - Country:US
Mailing Address - Phone:310-277-2771
Mailing Address - Fax:310-277-5184
Practice Address - Street 1:2080 CENTURY PARK EAST
Practice Address - Street 2:SUITE 1006
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067
Practice Address - Country:US
Practice Address - Phone:310-277-2771
Practice Address - Fax:310-277-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G201790Medicaid
CA00G201790Medicaid
CAW3059Medicare PIN