MEDICARE: DR. MARK WELLISCH 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	207X00000X	Orthopaedic Surgery Physician	A23373	CA
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	A23373	CA
3	2080S0010X	Pediatric Sports Medicine Physician	A23373	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982685996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WELLISCH M.D.

Provider Business Mailing Address
First Line	:	16311 VENTURA BLVD
Second Line	:	SUITE 800
City	:	ENCINO
State	:	CA
Zip	:	91436-2124
Country	:	US
Telephone Number	:	818-788-7343
Fax Number	:	818-788-9453

Provider Business Practice Location Address
First Line	:	16311 VENTURA BLVD
Second Line	:	SUITE 800
City	:	ENCINO
State	:	CA
Zip	:	91436-2124
Country	:	US
Telephone Number	:	818-788-7343
Fax Number	:	818-788-9453

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

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	09/11/2025

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Directions to “ DR. MARK WELLISCH M.D.” Practice Location

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