Healthcare Provider Details

I. General information

NPI: 1992296420
Provider Name (Legal Business Name): TREVIN THURMAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 W OLYMPIC BLVD STE 640
LOS ANGELES CA
90064-1525
US

IV. Provider business mailing address

13428 MAXELLA AVE STE 461
MARINA DEL REY CA
90292-5620
US

V. Phone/Fax

Practice location:
  • Phone: 310-853-6390
  • Fax:
Mailing address:
  • Phone: 310-853-6390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA114470
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA114470
License Number StateCA

VIII. Authorized Official

Name: TREVIN THURMAN
Title or Position: MD
Credential:
Phone: 310-853-6390