Healthcare Provider Details

I. General information

NPI: 1700076411
Provider Name (Legal Business Name): PHILIP WROTSLAVSKY, DPM, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD SUITE E-6
POWAY CA
92064-2435
US

IV. Provider business mailing address

PO BOX 13613
LA JOLLA CA
92039-3613
US

V. Phone/Fax

Practice location:
  • Phone: 888-451-3770
  • Fax: 888-600-8694
Mailing address:
  • Phone: 888-451-3770
  • Fax: 888-600-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberE4717
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberE4717
License Number StateCA

VIII. Authorized Official

Name: DR. PHILIP WROTSLAVSKY
Title or Position: CEO
Credential: DPM
Phone: 888-451-3770