=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740313709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY MAX WACHSMAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8700 BEVERLY BLVD ROOM M 335
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-423-6500
-----------------------------------------------------
Fax | 310-423-5654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 RANCHO CONEJO BLVD SUITE 201
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-375-8800
-----------------------------------------------------
Fax | 805-375-8900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | G81644
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------