Healthcare Provider Details

I. General information

NPI: 1639157100
Provider Name (Legal Business Name): PATRICK T. BEZDEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 SAN VICENTE BLVD SUITE 904
LOS ANGELES CA
90049-5012
US

IV. Provider business mailing address

11980 SAN VICENTE BLVD
LOS ANGELES CA
90049-6607
US

V. Phone/Fax

Practice location:
  • Phone: 310-820-2995
  • Fax: 310-454-2587
Mailing address:
  • Phone: 310-820-2995
  • Fax: 310-454-2587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG27084
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG27084
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: