Healthcare Provider Details

I. General information

NPI: 1699092023
Provider Name (Legal Business Name): L. IRI KUPFERWASSER MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2010
Last Update Date: 04/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16119 VANOWEN ST
VAN NUYS CA
91406-4822
US

IV. Provider business mailing address

16119 VANOWEN ST
VAN NUYS CA
91406-4822
US

V. Phone/Fax

Practice location:
  • Phone: 818-904-6782
  • Fax: 818-904-5896
Mailing address:
  • Phone: 818-904-6782
  • Fax: 818-904-5896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA83900
License Number StateCA

VIII. Authorized Official

Name: DR. LEON IRI KUPFERWASSER
Title or Position: PRESIDENT
Credential: MD
Phone: 310-210-3883