Provider Demographics
NPI:1821102922
Name:WULFSBERG, RICHARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:WULFSBERG
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 1:16030 VENTURA BLVD
Mailing Address - Street 2:SUITE 680
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2731
Mailing Address - Country:US
Mailing Address - Phone:818-990-1067
Mailing Address - Fax:818-981-1217
Practice Address - Street 1:16030 VENTURA BLVD
Practice Address - Street 2:SUITE 680
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2731
Practice Address - Country:US
Practice Address - Phone:818-990-1067
Practice Address - Fax:818-981-1217
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20755174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG20755OtherMEDICAL LICENSE
CAG20755OtherMEDICAL LICENSE
A41056Medicare UPIN