Healthcare Provider Details

I. General information

NPI: 1922268408
Provider Name (Legal Business Name): ALLAN ISAAC NUTKIEWICZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17915 VENTURA BLVD STE 220
ENCINO CA
91316-4810
US

IV. Provider business mailing address

17915 VENTURA BLVD STE 220
ENCINO CA
91316-4810
US

V. Phone/Fax

Practice location:
  • Phone: 818-938-9175
  • Fax: 818-938-9173
Mailing address:
  • Phone: 818-938-9175
  • Fax: 818-938-9173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberA32050
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA32050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: