Provider Demographics
NPI:1023065620
Name:SELAK STANKOVIC, RENATA (MD)
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:SELAK STANKOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19950 RINALDI ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-4141
Practice Address - Country:US
Practice Address - Phone:818-271-2400
Practice Address - Fax:818-271-2401
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC54463207R00000X
AZ34370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ089247Medicaid