=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104016856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERWINN MARTIN C SISTOZA, M.D.,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2007
-----------------------------------------------------
Last Update Date | 01/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1711 W TEMPLE ST SUITE 5638
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-989-6107
-----------------------------------------------------
Fax | 310-989-6519
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6355 GREEN VALLEY CIR UNIT 115
-----------------------------------------------------
City | CULVER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90230-7073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-348-9138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERWINN C SISTOZA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-348-9138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A76101
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | A76101
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------