Provider Demographics
NPI:1578577011
Name:AMONIC, ROBERT STEPHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STEPHAN
Last Name:AMONIC
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 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 790-W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-7821
Mailing Address - Fax:310-453-6541
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 790-W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-829-7821
Practice Address - Fax:310-453-6541
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA213802086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A213800OtherMEDICAL PPIN #
CAB49924Medicare UPIN
CAWA21380BMedicare ID - Type UnspecifiedPPIN #