Basic Information
| Provider Information | |||||||||
| NPI: | 1407825128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC REGENTS UCLA DMPG DERMATIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24DD5 WESTWOOD STATION | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018708 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1131 WILSHIRE BLVD | ||||||||
| Address2: | UC REGENTS UCLA DMPG DERMATOLOGY SUITE 200 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109173376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| 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 | 207N00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NI0002X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Clinical & Laboratory Dermatological Immunology |
ID Information
| ID | Type | State | Issuer | Description | W11919A | 01 | CA | MEDICARE PROVIDER NUMBER | OTHER |