Basic Information
| Provider Information | |||||||||
| NPI: | 1962436311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASSIL | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 N. ROXBURY DR. 3RD FL. | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104538911 | ||||||||
| FaxNumber: | 3104532519 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 N. ROXBURY DR. 3RD FL. | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104538911 | ||||||||
| FaxNumber: | 3104532519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | G62647 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00G626470 | 05 | CA | MEDICAID |