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General NPI Number Information
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NPI Number | 1700980828
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Entity Type | Organization
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Legal Business Name | OAK TREE MEDICAL CORPORATION
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Dates
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Enumeration Date | 09/11/2006
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Last Update Date | 08/28/2008
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Provider Practice Location Address
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Address Line | 751 CORDOVA STREET SUITE #1
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City | PASADENA
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State | CA
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Zip | 91101-2617
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Country | US
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Telephone | 626-577-2424
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Fax | 626-577-2995
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Provider Business Mailing Address
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Address Line | 751 CORDOVA STREET SUITE #1
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City | PASADENA
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State | CA
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Zip | 91101-2617
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Country | US
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Telephone | 626-577-2424
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Fax | 626-577-2995
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Authorized Official
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Title or Position | ADMINISTRATIVE DIRECTOR
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Name | MR. ROBERT EDMUND WYCOFF
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Credential | BA
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Telephone | 626-577-3415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State | CA
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