Healthcare Provider Details

I. General information

NPI: 1821102922
Provider Name (Legal Business Name): RICHARD L WULFSBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16030 VENTURA BLVD SUITE 680
ENCINO CA
91436-2731
US

IV. Provider business mailing address

16030 VENTURA BLVD SUITE 680
ENCINO CA
91436-2731
US

V. Phone/Fax

Practice location:
  • Phone: 818-990-1067
  • Fax: 818-981-1217
Mailing address:
  • Phone: 818-990-1067
  • Fax: 818-981-1217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG20755
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG20755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: