Provider Demographics
NPI:1366762338
Name:WALTER D DISHELL MD A MEDICAL CLINIC
Entity type:Organization
Organization Name:WALTER D DISHELL MD A MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:DISHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-986-7900
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 550
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-986-7900
Mailing Address - Fax:818-986-7952
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 550
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-986-7900
Practice Address - Fax:818-986-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-01
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC274780207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760568901OtherINDIVIDUAL NPI
CAC27478Medicare PIN
CAA33379Medicare UPIN