Provider Demographics
NPI:1932153970
Name:BAZAK, ILAN (DPM)
Entity type:Individual
Prefix:DR
First Name:ILAN
Middle Name:
Last Name:BAZAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 N FAIRFOX AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046
Mailing Address - Country:US
Mailing Address - Phone:323-650-6363
Mailing Address - Fax:323-650-4377
Practice Address - Street 1:1121 N FAIRFOX AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046
Practice Address - Country:US
Practice Address - Phone:323-650-6363
Practice Address - Fax:323-650-4377
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3741213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U11985Medicare UPIN
CAE3741BMedicare ID - Type Unspecified