Provider Demographics
NPI:1790796753
Name:BARDOWELL, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BARDOWELL
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 1:815 S ARDMORE AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-2597
Mailing Address - Country:US
Mailing Address - Phone:818-209-7575
Mailing Address - Fax:818-217-8564
Practice Address - Street 1:815 S ARDMORE AVE FL 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-2597
Practice Address - Country:US
Practice Address - Phone:818-209-7575
Practice Address - Fax:818-217-8564
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41037207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A410370Medicaid
CAA29280Medicare UPIN