Provider Demographics
NPI:1023158060
Name:BDIL, GENNADY GARY
Entity type:Individual
Prefix:
First Name:GENNADY
Middle Name:GARY
Last Name:BDIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-1716
Mailing Address - Country:US
Mailing Address - Phone:323-651-5976
Mailing Address - Fax:323-651-5367
Practice Address - Street 1:453 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-1716
Practice Address - Country:US
Practice Address - Phone:323-651-5976
Practice Address - Fax:323-651-5367
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD 6860156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX006860FMedicaid