Healthcare Provider Details

I. General information

NPI: 1205918588
Provider Name (Legal Business Name): WARREN SCOTT LINE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST SUITE #320
BURBANK CA
91505-4554
US

IV. Provider business mailing address

191 S BUENA VISTA ST SUITE #320
BURBANK CA
91505-4554
US

V. Phone/Fax

Practice location:
  • Phone: 818-559-9727
  • Fax: 818-559-5514
Mailing address:
  • Phone: 818-559-9727
  • Fax: 818-559-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberG48150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: