Provider Demographics
NPI:1346290814
Name:O'BRIEN, WALTER R (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:R
Last Name:O'BRIEN
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 1:11710 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1503
Mailing Address - Country:US
Mailing Address - Phone:310-477-7276
Mailing Address - Fax:310-477-5148
Practice Address - Street 1:11600 WILSHIRE BLVD
Practice Address - Street 2:SUITE 522
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5781
Practice Address - Country:US
Practice Address - Phone:310-477-7276
Practice Address - Fax:310-477-5148
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG063193207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G631931Medicaid
CA00G631931Medicaid
CA00G631931Medicaid
CAC65186Medicare UPIN
CA0372310001Medicare NSC