Provider Demographics
NPI:1568599678
Name:CHAFETZ, NEIL IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:IRA
Last Name:CHAFETZ
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 1:1360 W 6TH STREET
Mailing Address - Street 2:WEST BLDG STE 150
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732
Mailing Address - Country:US
Mailing Address - Phone:310-833-1724
Mailing Address - Fax:888-469-5935
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:WEST BLDG - STE. 100
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-833-2233
Practice Address - Fax:310-833-2213
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29504174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G295042Medicaid
CA00G295042Medicaid
CA300053916Medicare ID - Type UnspecifiedRAILROAD
CAA44058Medicare UPIN