Basic Information
| Provider Information | |||||||||
| NPI: | 1790712438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKINNER | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 EASTLAKE AVE | ||||||||
| Address2: | SUITE 7414 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900890177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238653700 | ||||||||
| FaxNumber: | 3238650120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 EASTLAKE AVE | ||||||||
| Address2: | SUITE 7414 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900890177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238653700 | ||||||||
| FaxNumber: | 3238650120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 06/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | G17316 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00G173160 | 05 | CA | MEDICAID |