Healthcare Provider Details

I. General information

NPI: 1982685996
Provider Name (Legal Business Name): MARK WELLISCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16311 VENTURA BLVD SUITE 800
ENCINO CA
91436-2124
US

IV. Provider business mailing address

16311 VENTURA BLVD SUITE 800
ENCINO CA
91436-2124
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-7343
  • Fax: 818-788-9453
Mailing address:
  • Phone: 818-788-7343
  • Fax: 818-788-9453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA23373
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA23373
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberA23373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: