Healthcare Provider Details

I. General information

NPI: 1588653943
Provider Name (Legal Business Name): PROSTATE ONCOLOGY SPECIALISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 ADMIRALTY WAY STE 111
MARINA DEL REY CA
90292-5424
US

IV. Provider business mailing address

4560 ADMIRALTY WAY STE 111
MARINA DEL REY CA
90292-5424
US

V. Phone/Fax

Practice location:
  • Phone: 310-827-7707
  • Fax: 310-574-4002
Mailing address:
  • Phone: 310-827-7707
  • Fax: 310-574-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG52827
License Number StateCA

VIII. Authorized Official

Name: DR. MARK C. SCHOLZ
Title or Position: PRESIDENT, MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-827-7707