Healthcare Provider Details

I. General information

NPI: 1457614984
Provider Name (Legal Business Name): STEPHEN KOLB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 05/07/2024
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 CLARK ST
TARZANA CA
91356-3501
US

IV. Provider business mailing address

5315 TORRANCE BLVD STE B1
TORRANCE CA
90503-4011
US

V. Phone/Fax

Practice location:
  • Phone: 818-514-5314
  • Fax:
Mailing address:
  • Phone: 818-514-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA147359
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA147359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: