Provider Demographics
NPI:1255365938
Name:SAMOVITZ, MYRON (MD)
Entity type:Individual
Prefix:
First Name:MYRON
Middle Name:
Last Name:SAMOVITZ
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 1:416 N BEDFORD DR
Mailing Address - Street 2:206
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4322
Mailing Address - Country:US
Mailing Address - Phone:310-278-5025
Mailing Address - Fax:310-278-1558
Practice Address - Street 1:416 N BEDFORD DR
Practice Address - Street 2:206
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4322
Practice Address - Country:US
Practice Address - Phone:310-278-5025
Practice Address - Fax:310-278-1558
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-02-04
Deactivation Date:2018-10-29
Deactivation Code:
Reactivation Date:2019-02-04
Provider Licenses
StateLicense IDTaxonomies
CAC26830207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33225Medicare UPIN
CAWC26830DMedicare PIN