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Provider Information for 1619119187

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1619119187

Calendar   Last Updated:  2012-07-11
  Certification Date: 


Name Value
NPI 1619119187
Enumeration Date 2009-03-30
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 10833 LE CONTE AVE 12-358 CHS
LOS ANGELES, CA 90095-3075
United States

Phone: 714-396-1217 | Fax:
View Map External Link
Primary Practice Address 200 MEDICAL PLZ 265
LOS ANGELES, CA 90095-0001
United States

Phone: 310-825-9346 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 208000000X - Pediatrics CA A115680
No 390200000X - Student in an Organized Health Care Education/Training Program