MEDICARE: DR. MORITZ SEBASTIAN PETTENKOFER MD

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	207WX0107X	Retina Specialist (Ophthalmology) Physician	SPI621	CA

General Provider Information

NPI Number	:	1194455188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MORITZ SEBASTIAN PETTENKOFER MD

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:	310-301-8707
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 STEIN PLAZA DRIVEWAY 3RD FLOOR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-0001
Country	:	US
Telephone Number	:	310-206-5004
Fax Number	:

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

Provider Enumeration Date	:	06/13/2022
Last Update Date	:	09/28/2022

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