Healthcare Provider Details

I. General information

NPI: 1821164070
Provider Name (Legal Business Name): WIRELESS DIAGNOSTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK EAST #1206
LOS ANGELES CA
90067
US

IV. Provider business mailing address

9589 STUART LANE
BEVERLY HILLS CA
90210
US

V. Phone/Fax

Practice location:
  • Phone: 310-282-0525
  • Fax: 310-201-0662
Mailing address:
  • Phone: 310-282-0525
  • Fax: 310-201-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA61044
License Number StateCA

VIII. Authorized Official

Name: NICHOLAS KARYOTAKIS
Title or Position: OWNER
Credential: MD
Phone: 310-282-0525