Provider Demographics
NPI:1801805874
Name:MEDICAL GROUP OF ENCINO, INC
Entity type:Organization
Organization Name:MEDICAL GROUP OF ENCINO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:WULFSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-990-1067
Mailing Address - Street 1:16030 VENTURA BOULEVARD
Mailing Address - Street 2:SUITE 680
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2726
Mailing Address - Country:US
Mailing Address - Phone:818-990-1067
Mailing Address - Fax:818-981-1217
Practice Address - Street 1:16030 VENTURA BOULEVARD
Practice Address - Street 2:SUITE 680
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2726
Practice Address - Country:US
Practice Address - Phone:818-990-1067
Practice Address - Fax:818-981-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W1216Medicare ID - Type Unspecified