Basic Information
| Provider Information | |||||||||
| NPI: | 1316408719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENNEBERG | ||||||||
| FirstName: | CAMERON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018707 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PLAZA SUITE 420 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900954033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102066232 | ||||||||
| FaxNumber: | 3102063551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2019 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A177235 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.