Basic Information
| Provider Information | |||||||||
| NPI: | 1720213101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABBOTT | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | EMMANUEL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1127 WILSHIRE BLVD STE 805 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900173909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139771176 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6110 ELTON AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891072538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029062976 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 20A11538 | CA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | DO2639 | NV | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.