Provider Demographics
NPI:1285810655
Name:PTAK, JEFFREY ELLIOT (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ELLIOT
Last Name:PTAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11545 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1508
Mailing Address - Country:US
Mailing Address - Phone:310-473-7991
Mailing Address - Fax:310-473-7921
Practice Address - Street 1:11545 W OLYMPIC BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1508
Practice Address - Country:US
Practice Address - Phone:310-473-7991
Practice Address - Fax:310-473-7921
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC17586AMedicare PIN
CAT17581Medicare UPIN