Healthcare Provider Details

I. General information

NPI: 1235166075
Provider Name (Legal Business Name): ROBERT SCOTT VENICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LECONTE AVE 12-441 MDCC
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6134
  • Fax: 310-206-0203
Mailing address:
  • Phone: 310-206-6134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA77078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: