Healthcare Provider Details

I. General information

NPI: 1366112724
Provider Name (Legal Business Name): ALEXANDER CHRISTOPHER WULFF DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date: 05/14/2022
Reactivation Date: 06/08/2022

III. Provider practice location address

4560 ADMIRALTY WAY STE 100
MARINA DEL REY CA
90292-5424
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 310-827-3700
  • Fax:
Mailing address:
  • Phone: 310-301-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A21410
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A21410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: