Provider Demographics
NPI:1861487969
Name:YABLONICKY, KEITH JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JOSEPH
Last Name:YABLONICKY
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 1:1200 N STATE ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-226-6937
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-226-6937
Practice Address - Fax:323-226-6454
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81617208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861487969Medicaid
CABV142XMedicare PIN