Healthcare Provider Details

I. General information

NPI: 1164448734
Provider Name (Legal Business Name): MARK AGULNIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVE
LOS ANGELES CA
90089-3012
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-3000
  • Fax:
Mailing address:
  • Phone: 323-865-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036-118071
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberC170270
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: