Basic Information
| Provider Information | |||||||||
| NPI: | 1972777332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKORETZ | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11401 BLOOMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628637011 | ||||||||
| FaxNumber: | 9094256635 | ||||||||
| Practice Location | |||||||||
| Address1: | 11401 BLOOMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628637011 | ||||||||
| FaxNumber: | 9094256635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/10/2017 | ||||||||
| NPIReactivationDate: | 01/13/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | A112842 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.