Healthcare Provider Details

I. General information

NPI: 1295291607
Provider Name (Legal Business Name): MR. ANTON PAVLOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N KEYSTONE ST STE B
BURBANK CA
91506-1900
US

IV. Provider business mailing address

640 N KEYSTONE ST STE B
BURBANK CA
91506-1900
US

V. Phone/Fax

Practice location:
  • Phone: 818-846-8666
  • Fax: 818-846-8665
Mailing address:
  • Phone: 818-846-8666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246YR1600X
TaxonomyRegistered Record Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: