Healthcare Provider Details

I. General information

NPI: 1700980828
Provider Name (Legal Business Name): OAK TREE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 CORDOVA STREET SUITE #1
PASADENA CA
91101-2617
US

IV. Provider business mailing address

751 CORDOVA STREET SUITE #1
PASADENA CA
91101-2617
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2424
  • Fax: 626-577-2995
Mailing address:
  • Phone: 626-577-2424
  • Fax: 626-577-2995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. ROBERT EDMUND WYCOFF
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: BA
Phone: 626-577-3415