=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184729352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL VICTOR EHRENSAFT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3831 HUGHES AVE SUITE 603
-----------------------------------------------------
City | CULVER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-202-9145
-----------------------------------------------------
Fax | 310-202-0188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-3699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-202-9145
-----------------------------------------------------
Fax | 310-202-0188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | G22676
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------