Healthcare Provider Details

I. General information

NPI: 1396939351
Provider Name (Legal Business Name): CARRIE M. WAMBACH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARRIE M. WAMBACH

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N ROXBURY DR
BEVERLY HILLS CA
90210-4231
US

IV. Provider business mailing address

14445 OLIVE VIEW DR RM 6B119 H
SYLMAR CA
91342
US

V. Phone/Fax

Practice location:
  • Phone: 310-277-2393
  • Fax:
Mailing address:
  • Phone: 818-364-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA99236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: