Provider Demographics
NPI:1073651261
Name:J TIMOTHY KATZEN MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:J TIMOTHY KATZEN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:KATZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-859-7770
Mailing Address - Street 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:STE. 440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-471-5852
Mailing Address - Fax:310-471-3958
Practice Address - Street 1:9735 WILSHIRE BLVD
Practice Address - Street 2:#407
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2107
Practice Address - Country:US
Practice Address - Phone:310-471-5852
Practice Address - Fax:310-471-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85745208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABL320OtherMEDICARE ID TYPE UNSPECIFIED