Provider Demographics
NPI:1558403493
Name:WROTSLAVSKY, PHILIP (DPM, CEO)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:WROTSLAVSKY
Suffix:
Gender:M
Credentials:DPM, CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13613
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92039-3613
Mailing Address - Country:US
Mailing Address - Phone:888-451-3770
Mailing Address - Fax:888-600-8694
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE E-6
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-451-2280
Practice Address - Fax:858-451-2006
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4717213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery