1932330867 NPI number — DR. OREST V PETRISHEN N.D., PH.D., C.N.C.

Table of content: (NPI 1730239450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932330867 NPI number — DR. OREST V PETRISHEN N.D., PH.D., C.N.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRISHEN
Provider First Name:
OREST
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
N.D., PH.D., C.N.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932330867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6333 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
STE #200
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90048-5702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-382-4211
Provider Business Mailing Address Fax Number:
323-654-5373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6333 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
STE #200
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-5702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-653-2504
Provider Business Practice Location Address Fax Number:
323-653-2515
Provider Enumeration Date:
07/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133N00000X , with the licence number:  CNC-2372 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 175F00000X , with the licence number: NAT-375 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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