MEDICARE: SEAN JOSEPH WOLLASTON M.D.

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	174400000X	Specialist	A63797	CA

General Provider Information

NPI Number	:	1316921075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN JOSEPH WOLLASTON M.D.

Provider Business Mailing Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	SUITE 200
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3429
Country	:	US
Telephone Number	:	818-980-7010
Fax Number	:	818-980-7330

Provider Business Practice Location Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	SUITE 200
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3429
Country	:	US
Telephone Number	:	818-980-7010
Fax Number	:	818-980-7330

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

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	09/26/2011

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