Provider Demographics
NPI:1972625069
Name:BASSUK, PABLO JAVIER (MD)
Entity Type:Individual
Prefix:DR
First Name:PABLO
Middle Name:JAVIER
Last Name:BASSUK
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:PO BOX 2027
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-2027
Mailing Address - Country:US
Mailing Address - Phone:323-943-8577
Mailing Address - Fax:
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:747-273-1129
Practice Address - Fax:818-356-4465
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972625069Medicaid
CAGG103ZMedicare PIN
CAI74198Medicare UPIN
CA00A990570Medicaid
CACB227131Medicare PIN