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General NPI Number Information
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NPI Number | 1154802346
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Entity Type | Organization
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Legal Business Name | WK MD MEDICAL GROUP INC
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Dates
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Enumeration Date | 08/24/2018
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Last Update Date | 08/24/2018
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Provider Practice Location Address
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Address Line | 1711 W TEMPLE ST
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City | LOS ANGELES
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State | CA
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Zip | 90026-5421
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Country | US
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Telephone | 323-662-4222
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Fax |
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Provider Business Mailing Address
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Address Line | 1711 W TEMPLE ST
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City | LOS ANGELES
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State | CA
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Zip | 90026-5421
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Country | US
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Telephone | 323-662-4222
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | WALTER KWOCK
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Credential | MD
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Telephone | 323-662-4222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A21085
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License Number State | CA
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