Basic Information
Provider Information | |||||||||
NPI: | 1164487518 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UCLA PLASTIC SURGERY ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5767 W CENTURY BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900455632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103018708 | ||||||||
FaxNumber: | 3103018751 | ||||||||
Practice Location | |||||||||
Address1: | 200 MEDICAL PLZ | ||||||||
Address2: | SUITE 465 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900950001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108255510 | ||||||||
FaxNumber: | 3103018751 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 10/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRISSEY | ||||||||
AuthorizedOfficialFirstName: | MARCIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3108255318 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0099X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2082S0105X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 208200000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | GR0067460 | 05 | CA |   | MEDICAID |