Provider Demographics
NPI:1992044358
Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARAVARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-282-0011
Mailing Address - Street 1:2121 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5720
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:
Practice Address - Street 1:295 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-1020
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4186213E00000X
CAE4928213E00000X
CAE3141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16343Medicare PIN