Healthcare Provider Details

I. General information

NPI: 1346290814
Provider Name (Legal Business Name): WALTER R O'BRIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 03/07/2023
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 WILSHIRE BLVD SUITE 522
LOS ANGELES CA
90025-5781
US

IV. Provider business mailing address

11710 WILSHIRE BLVD
LOS ANGELES CA
90025-1503
US

V. Phone/Fax

Practice location:
  • Phone: 310-477-7276
  • Fax: 310-477-5148
Mailing address:
  • Phone: 310-477-7276
  • Fax: 310-477-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG063193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: