Provider Demographics
NPI:1063695302
Name:BORIS BERZON MD INC
Entity type:Organization
Organization Name:BORIS BERZON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BERZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-730-5600
Mailing Address - Street 1:3631 CRENSHAW BLVD
Mailing Address - Street 2:STE 102 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-4869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3631 CRENSHAW BLVD
Practice Address - Street 2:STE 102 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4869
Practice Address - Country:US
Practice Address - Phone:323-730-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA70349OtherLICENSE
=========OtherTIN
CAA70349OtherLICENSE