Basic Information
| Provider Information | |||||||||
| NPI: | 1437113636 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEBAK | ||||||||
| FirstName: | SANDRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 56765 | ||||||||
| Address2: | LOCK BOX | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900746765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063860 | ||||||||
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| Practice Location | |||||||||
| Address1: | 655 S DOBSON RD | ||||||||
| Address2: | B113 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807285020 | ||||||||
| FaxNumber: | 4808995023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18834 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 318031 | 05 | AZ | MEDICAID |