Healthcare Provider Details

I. General information

NPI: 1659517654
Provider Name (Legal Business Name): UC REGENTS UCLA UROLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2008
Last Update Date: 12/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ SUITE 365
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-1632
  • Fax:
Mailing address:
  • Phone: 310-301-8708
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License NumberF5519
License Number StateCA

VIII. Authorized Official

Name: PROF. JEAN DEKERNION
Title or Position: CHAIR
Credential: M.D.
Phone: 310-301-8751