MEDICARE: FRED KYAZZE M D INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	A51997	CA

General Provider Information

NPI Number	:	1528350014
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED KYAZZE M D INC

Provider Business Mailing Address
First Line	:	1410 W ALONDRA BLVD
Second Line	:	SUITE C
City	:	COMPTON
State	:	CA
Zip	:	90220-3533
Country	:	US
Telephone Number	:	310-637-3680
Fax Number	:	310-637-3679

Provider Business Practice Location Address
First Line	:	1410 W ALONDRA BLVD
Second Line	:	SUITE C
City	:	COMPTON
State	:	CA
Zip	:	90220-3533
Country	:	US
Telephone Number	:	310-637-3680
Fax Number	:	310-637-3679

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	FRED KYAZZE
Credential	:	M.D.
Telephone Number	:	310-637-3680

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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