Healthcare Provider Details

I. General information

NPI: 1104016856
Provider Name (Legal Business Name): ERWINN MARTIN C SISTOZA, M.D.,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 W TEMPLE ST SUITE 5638
LOS ANGELES CA
90026-5421
US

IV. Provider business mailing address

6355 GREEN VALLEY CIR UNIT 115
CULVER CITY CA
90230-7073
US

V. Phone/Fax

Practice location:
  • Phone: 310-989-6107
  • Fax: 310-989-6519
Mailing address:
  • Phone: 310-348-9138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA76101
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA76101
License Number StateCA

VIII. Authorized Official

Name: DR. ERWINN C SISTOZA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-348-9138