Provider Demographics
NPI:1881695286
Name:FLESHNER, PHILLIP ROBERT (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ROBERT
Last Name:FLESHNER
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 1:8737 BEVERLY BLVD
Mailing Address - Street 2:#101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1835
Mailing Address - Country:US
Mailing Address - Phone:310-289-9277
Mailing Address - Fax:310-289-8995
Practice Address - Street 1:8737 BEVERLY BLVD
Practice Address - Street 2:#101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-1835
Practice Address - Country:US
Practice Address - Phone:310-289-9277
Practice Address - Fax:310-289-8995
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-06-19
Deactivation Date:2006-04-11
Deactivation Code:
Reactivation Date:2006-06-27
Provider Licenses
StateLicense IDTaxonomies
CAG071920208C00000X
CAG71920208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G71920Medicare ID - Type Unspecified
E86477Medicare UPIN