Healthcare Provider Details

I. General information

NPI: 1295882496
Provider Name (Legal Business Name): SERGE OBUKHOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SERGE OBUKHOV M.D.

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 WILSHIRE BLVD
LOS ANGELES CA
90048-5801
US

IV. Provider business mailing address

27159 SEA VISTA DR
MALIBU CA
90265-4436
US

V. Phone/Fax

Practice location:
  • Phone: 323-933-3200
  • Fax:
Mailing address:
  • Phone: 310-457-7421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberB65490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: