Healthcare Provider Details

I. General information

NPI: 1982645602
Provider Name (Legal Business Name): GEORGE P. TEITELBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SANTA MONICA BLVD
SANTA MONICA CA
90404-2303
US

IV. Provider business mailing address

501 S BUENA VISTA ST PROVIDENCE NEUROVASCULAR CENTER
BURBANK CA
91505-4809
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8319
  • Fax: 310-582-7495
Mailing address:
  • Phone: 818-847-4835
  • Fax: 818-847-4842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG45097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: