Basic Information
| Provider Information | |||||||||
| NPI: | 1093025355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UCLA DEPARTMENT OF PEDIATRIC GROUP PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10833 LE CONTE AVE | ||||||||
| Address2: | 22-474 MDCC | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900951752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108256196 | ||||||||
| FaxNumber: | 3108255834 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PLZ | ||||||||
| Address2: | SUITE 265 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108250867 | ||||||||
| FaxNumber: | 3102065146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | DEVASKAR | ||||||||
| AuthorizedOfficialFirstName: | SHERIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM EXECUTIVE CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 3108255095 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 677319 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Pediatrics | 363LF0000X | 19341 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.