Basic Information
| Provider Information | |||||||||
| NPI: | 1588619928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YAWITZ | ||||||||
| FirstName: | BRUCE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21559 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887271073 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2202 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904035706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102649000 | ||||||||
| FaxNumber: | 3102649004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G73672 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G736720 | 01 | CA | BLUE SHIELD OF CA | OTHER | 00G736720 | 05 | CA | MEDICAID |