Basic Information
| Provider Information | |||||||||
| NPI: | 1316905326 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC REGENTS UCLA DMPG BRENTWOOD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24DD5 | ||||||||
| Address2: | WESTWOOD STATION | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900240001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018708 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 11980 SAN VICENTE BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102087777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OYE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE CHAIR OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3102060644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207RA0000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Adolescent Medicine |
No ID Information.