Provider Demographics
NPI:1053334243
Name:MOHLENBROCK, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:MOHLENBROCK
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 1:9850 GENESEE AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1206
Mailing Address - Country:US
Mailing Address - Phone:858-535-1075
Mailing Address - Fax:858-453-9810
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:STE 210
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1206
Practice Address - Country:US
Practice Address - Phone:858-535-1075
Practice Address - Fax:858-453-9810
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29014207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A87309Medicare UPIN
W15730AMedicare ID - Type Unspecified
W15730Medicare ID - Type Unspecified