Healthcare Provider Details

I. General information

NPI: 1083820716
Provider Name (Legal Business Name): DEAN MICHAEL ANSELMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

6430 W SUNSET BLVD STE 600
LOS ANGELES CA
90028-7909
US

V. Phone/Fax

Practice location:
  • Phone: 323-660-2450
  • Fax:
Mailing address:
  • Phone: 323-669-2337
  • Fax: 323-644-8491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA70021
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA70021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: