Basic Information
| Provider Information | |||||||||
| NPI: | 1730250556 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KERRY K. ASSIL, M.D., INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASSIL EYE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 N ROXBURY DR | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902104232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104538911 | ||||||||
| FaxNumber: | 3104532519 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 N ROXBURY DR | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902104232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104538911 | ||||||||
| FaxNumber: | 3104532519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 11/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | ASSIL | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3104538911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | G62647 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00G626470 | 05 | CA | MEDICAID |