=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467558684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLEN M.ENTIN, M.D. AND FELICIA A.OTA, M.D., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 09/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18370 BURBANK BLVD SUITE 100
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-708-1090
-----------------------------------------------------
Fax | 818-708-3238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18370 BURBANK BLVD SUITE 100
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-708-1090
-----------------------------------------------------
Fax | 818-708-3238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | DR. ALLEN M ENTIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-708-1090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | A65703
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | G32015
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------