Healthcare Provider Details

I. General information

NPI: 1750893707
Provider Name (Legal Business Name): UNIVERSITY FOOT & ANKLE INSTITUTE PODIACTRIC SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 10/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WILSHIRE BLVD STE 810
LOS ANGELES CA
90017-4808
US

IV. Provider business mailing address

2121 WILSHIRE BLVD STE 101
SANTA MONICA CA
90403-5742
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-0011
  • Fax: 310-828-2001
Mailing address:
  • Phone: 310-828-0011
  • Fax: 310-828-0011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE5283
License Number StateCA

VIII. Authorized Official

Name: BABAK BARAVARIAN
Title or Position: PARTNER
Credential:
Phone: 310-828-0011