MEDICARE: MARK SCHLOTTERBACK

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	390200000X	Student in an Organized Health Care Education/Training Program	90200000X
2	2084P0800X	Psychiatry Physician	172152	CA

General Provider Information

NPI Number	:	1346775921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK SCHLOTTERBACK

Provider Business Mailing Address
First Line	:	12301 WILSHIRE BLVD STE 512
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1053
Country	:	US
Telephone Number	:	888-684-2779
Fax Number	:

Provider Business Practice Location Address
First Line	:	12301 WILSHIRE BLVD STE 512
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1053
Country	:	US
Telephone Number	:	888-684-2779
Fax Number	:

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

Provider Enumeration Date	:	04/20/2017
Last Update Date	:	09/24/2021

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