Provider Demographics
NPI:1649414400
Name:GANELIS, IRINA B (MD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:B
Last Name:GANELIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9663 SANTA MONICA BLVD # 396
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4303
Mailing Address - Country:US
Mailing Address - Phone:310-773-3396
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:SUITE 523
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:818-394-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99531207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CX658AOtherPTAN