Provider Demographics
NPI:1194761486
Name:KASSINOVE, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:KASSINOVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30925 GANADO DR
Mailing Address - Street 2:RANCHO PALOS
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-6243
Mailing Address - Country:US
Mailing Address - Phone:310-951-1714
Mailing Address - Fax:
Practice Address - Street 1:2131 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1901
Practice Address - Country:US
Practice Address - Phone:213-484-7301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73936207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A739360Medicaid
CA00A739360Medicaid
CACE444ZMedicare PIN