Provider Demographics
NPI:1053392365
Name:BANNYKH, SERGUEI IVANOVICH (MD)
Entity type:Individual
Prefix:
First Name:SERGUEI
Middle Name:IVANOVICH
Last Name:BANNYKH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 BEVERLY BLVD
Mailing Address - Street 2:SUITE 8730
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:310-423-3562
Mailing Address - Fax:310-423-0122
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:SUITE 8730
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-423-3562
Practice Address - Fax:310-423-0122
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040897207ZN0500X, 207ZP0101X
CAA72353207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Not Answered207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H77477Medicare UPIN