Healthcare Provider Details

I. General information

NPI: 1114061421
Provider Name (Legal Business Name): MARGO PATRICIA DELEAVER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARGO PATRICIA DELEAVER-RUSSELL M.D.

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 HUGHES AVE STE 601
CULVER CITY CA
90232-6844
US

IV. Provider business mailing address

3831 HUGHES AVE STE 601
CULVER CITY CA
90232-6844
US

V. Phone/Fax

Practice location:
  • Phone: 310-838-4048
  • Fax: 310-838-0491
Mailing address:
  • Phone: 310-838-4048
  • Fax: 310-838-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC38896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: