=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982685996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK WELLISCH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2005
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16311 VENTURA BLVD SUITE 800
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-7343
-----------------------------------------------------
Fax | 818-788-9453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16311 VENTURA BLVD SUITE 800
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-7343
-----------------------------------------------------
Fax | 818-788-9453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | A23373
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | A23373
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080S0010X
-----------------------------------------------------
Taxonomy Name | Pediatric Sports Medicine Physician
-----------------------------------------------------
License Number | A23373
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------