Healthcare Provider Details

I. General information

NPI: 1790195410
Provider Name (Legal Business Name): CARDIOVASCULAR CONSULTANTS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16542 VENTURA BLVD SUITE 402
ENCINO CA
91436-2005
US

IV. Provider business mailing address

16542 VENTURA BLVD STE 402
ENCINO CA
91436-4562
US

V. Phone/Fax

Practice location:
  • Phone: 818-782-5041
  • Fax: 818-782-4864
Mailing address:
  • Phone: 818-782-5041
  • Fax: 818-205-9091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ISAAC WIENER
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 818-782-5041