Provider Demographics
NPI:1366487175
Name:MARK D. WOLFSOHN, M.D., ANESTHESIOLOGY MEDICAL CORP.
Entity Type:Organization
Organization Name:MARK D. WOLFSOHN, M.D., ANESTHESIOLOGY MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOLFSOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-440-3131
Mailing Address - Street 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:STE. 440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-440-3131
Mailing Address - Fax:310-472-9582
Practice Address - Street 1:261 MOBIL AVE
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6337
Practice Address - Country:US
Practice Address - Phone:805-484-8558
Practice Address - Fax:805-484-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34454207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G344540Medicaid
CAG34454BMedicare ID - Type Unspecified