Healthcare Provider Details

I. General information

NPI: 1750442448
Provider Name (Legal Business Name): GARY S BELLACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3 STREET STE 225
LOS ANGELES CA
90048
US

IV. Provider business mailing address

8631 W 3RD STREET #225
LOS ANGELES CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-3938
  • Fax: 310-659-4231
Mailing address:
  • Phone: 310-659-3938
  • Fax: 310-659-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberC42325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: