Provider Demographics
NPI:1700061553
Name:DEANRO A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DEANRO A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BILCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD, MBA
Authorized Official - Phone:310-449-5206
Mailing Address - Street 1:2200 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2312
Mailing Address - Country:US
Mailing Address - Phone:310-449-5206
Mailing Address - Fax:310-449-5242
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-449-5206
Practice Address - Fax:310-449-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA497662086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherBLUE CROSS
CA=========OtherBLUE CROSS