MEDICARE: DR. DIANA ELANA CHAVKIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VE0102X	Reproductive Endocrinology Physician	C148541	CA

General Provider Information

NPI Number	:	1417012535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA ELANA CHAVKIN MD

Provider Business Mailing Address
First Line	:	400 MOUNT HOLYOKE AVE
Second Line	:
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-4603
Country	:	US
Telephone Number	:	310-481-0881
Fax Number	:

Provider Business Practice Location Address
First Line	:	11500 W OLYMPIC BLVD STE 504
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1525
Country	:	US
Telephone Number	:	310-481-0881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	11/02/2017

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