Healthcare Provider Details

I. General information

NPI: 1851623029
Provider Name (Legal Business Name): WALTER R OBRIEN MD INC A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 WILSHIRE BLVD
LOS ANGELES CA
90025-1503
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 NumberG63193
License Number StateCA

VIII. Authorized Official

Name: MR. WALTER RAY O'BRIEN
Title or Position: OWNER
Credential: M D
Phone: 310-477-7276