Provider Demographics
NPI:1396906111
Name:ILAN BAZAK DPM PROFESSIONAL CORP
Entity type:Organization
Organization Name:ILAN BAZAK DPM PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:323-650-6363
Mailing Address - Street 1:1121 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5306
Mailing Address - Country:US
Mailing Address - Phone:323-650-6363
Mailing Address - Fax:323-650-4377
Practice Address - Street 1:1121 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5306
Practice Address - Country:US
Practice Address - Phone:323-650-6363
Practice Address - Fax:323-650-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0559350001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU11985Medicare UPIN
CAE3741BMedicare PIN
CA0559350001Medicare NSC