Provider Demographics
NPI:1295792505
Name:ALLAN S. WIRTZER
Entity type:Organization
Organization Name:ALLAN S. WIRTZER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:WIRTZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-907-7546
Mailing Address - Street 1:4836 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2101
Mailing Address - Country:US
Mailing Address - Phone:818-907-7546
Mailing Address - Fax:818-907-9506
Practice Address - Street 1:4836 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2101
Practice Address - Country:US
Practice Address - Phone:818-907-7546
Practice Address - Fax:818-907-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326003161OtherALLAN S. WIRTZER MD, MEDICAL DIRECTOR NPI#
CAS051305Medicare PIN