MEDICARE: WALTER VAN VORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	G63602	CA

General Provider Information

NPI Number	:	1013026160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER VAN VORT

Provider Business Mailing Address
First Line	:	11301 WILSHIRE BLVD # B116AA
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90073-1003
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11301 WILSHIRE BLVD # B116AA
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90073-1003
Country	:	US
Telephone Number	:	310-268-4449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	12/07/2025

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