Healthcare Provider Details

I. General information

NPI: 1083760995
Provider Name (Legal Business Name): RUSSELL J WOJCIK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 1/2 N LARCHMONT BLVD
LOS ANGELES CA
90004-3013
US

IV. Provider business mailing address

12807 ELKWOOD ST
NORTH HOLLYWOOD CA
91605-2035
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-1266
  • Fax:
Mailing address:
  • Phone: 213-385-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE1920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: