Healthcare Provider Details

I. General information

NPI: 1437116472
Provider Name (Legal Business Name): VICTOR ALBERT CANDIOTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 06/10/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SANTA MONICA BLVD EMERGENCY DEPT PROVIDENCE SAINT JOHN'S HEALTH CENTER
SANTA MONICA CA
90404-2091
US

IV. Provider business mailing address

PO BOX 12079
WESTMINSTER CA
92685
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7089
  • Fax: 310-582-7135
Mailing address:
  • Phone: 562-809-3595
  • Fax: 562-468-0347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG62022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: