Provider Demographics
NPI:1790956209
Name:ESP MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ESP MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:HANS
Authorized Official - Last Name:ESPENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-842-7145
Mailing Address - Street 1:PO BOX 16068
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91416-6068
Mailing Address - Country:US
Mailing Address - Phone:818-558-7075
Mailing Address - Fax:818-558-7081
Practice Address - Street 1:2601 W ALAMEDA AVE
Practice Address - Street 2:STE 208
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4800
Practice Address - Country:US
Practice Address - Phone:818-558-7075
Practice Address - Fax:818-558-7081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4419213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6382730001Medicare NSC
CAU90678Medicare UPIN