Provider Demographics
NPI:1750773727
Name:PABLO BASSUK M D INC
Entity type:Organization
Organization Name:PABLO BASSUK M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:J
Authorized Official - Last Name:BASSUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:747-273-1129
Mailing Address - Street 1:PO BOX 2027
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91209-2027
Mailing Address - Country:US
Mailing Address - Phone:747-273-1129
Mailing Address - Fax:
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:323-943-8577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB238521OtherPTAN