Healthcare Provider Details

I. General information

NPI: 1083749212
Provider Name (Legal Business Name): IRVIN S. BENOWITZ D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST STE. 420
BURBANK CA
91505-4554
US

IV. Provider business mailing address

777 FLOWER ST STE A
GLENDALE CA
91201-3000
US

V. Phone/Fax

Practice location:
  • Phone: 818-557-7399
  • Fax: 818-848-1543
Mailing address:
  • Phone: 818-637-2000
  • Fax: 818-242-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4228
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number20A4228
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number20A4228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: