Provider Demographics
NPI:1356523153
Name:UNIV HEAD & NECK SURGEON
Entity type:Organization
Organization Name:UNIV HEAD & NECK SURGEON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAKTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:714-456-3083
Mailing Address - Street 1:PO BOX 513700
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3700
Mailing Address - Country:US
Mailing Address - Phone:714-456-6655
Mailing Address - Fax:714-456-2280
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-7017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY HEAD & NECK SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1556237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGAU000750Medicaid