Provider Demographics
NPI:1891245619
Name:KEITH L. GURNICK, D.P.M.
Entity Type:Organization
Organization Name:KEITH L. GURNICK, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GURNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-553-7691
Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 705
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-553-7691
Mailing Address - Fax:310-553-9542
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 705
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-553-7691
Practice Address - Fax:310-553-9542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2615A332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E2615000OtherBLUE SHIELD
CAP1737210OtherOXFORD
CAT11404Medicare UPIN