Provider Demographics
NPI:1659511251
Name:KERRY K ASSIL, MD, INC.
Entity Type:Organization
Organization Name:KERRY K ASSIL, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ASSIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-453-8911
Mailing Address - Street 1:450 N ROXBURY DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4231
Mailing Address - Country:US
Mailing Address - Phone:310-453-8911
Mailing Address - Fax:310-453-2519
Practice Address - Street 1:2222 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2304
Practice Address - Country:US
Practice Address - Phone:310-453-8911
Practice Address - Fax:310-453-2519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14005Medicare PIN