Healthcare Provider Details

I. General information

NPI: 1750722088
Provider Name (Legal Business Name): UNIVERSITY FOOT AND ANKLE INSTITUTE A PPODIATRIC SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E AVENIDA DE LOS ARBOLES SUITE 101
THOUSAND OAKS CA
91360-3003
US

IV. Provider business mailing address

2121 WILSHIRE BLVD
SANTA MONICA CA
90403-5720
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3692
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3692
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE3692
License Number StateCA

VIII. Authorized Official

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