Provider Demographics
NPI:1760568901
Name:DISHELL, WALTER D (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:D
Last Name:DISHELL
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 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 550
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4314
Mailing Address - Country:US
Mailing Address - Phone:818-986-7900
Mailing Address - Fax:818-986-7952
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 550
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4314
Practice Address - Country:US
Practice Address - Phone:818-986-7900
Practice Address - Fax:818-986-7952
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC274780207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C27478Medicare ID - Type Unspecified
A33379Medicare UPIN