Provider Demographics
NPI:1316921075
Name:WOLLASTON, SEAN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:JOSEPH
Last Name:WOLLASTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12660 RIVERSIDE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3429
Mailing Address - Country:US
Mailing Address - Phone:818-980-7010
Mailing Address - Fax:818-980-7330
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-980-7010
Practice Address - Fax:818-980-7330
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63797174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH16546Medicare UPIN