Provider Demographics
NPI:1184866469
Name:H. RONALD FISK, M.D., PH.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:H. RONALD FISK, M.D., PH.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEILANI
Authorized Official - Middle Name:
Authorized Official - Last Name:LUAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-657-0942
Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 620E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-657-0942
Mailing Address - Fax:310-652-2499
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 620E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-657-0942
Practice Address - Fax:310-652-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG203002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89327Medicare UPIN