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Provider Information for 1639170228

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1639170228

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1639170228
Enumeration Date 2005-08-03
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 1172 N MACLAY AVE
SAN FERNANDO, CA 91340-1328
United States

Phone: 818-898-1388 | Fax: 818-365-4031
View Map External Link
Primary Practice Address 23763 VALENCIA BLVD
VALENCIA, CA 91355-2105
United States

Phone: 661-287-1551 | Fax: 661-255-8037
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 207R00000X - Internal Medicine CA G6961