Healthcare Provider Details

I. General information

NPI: 1164569091
Provider Name (Legal Business Name): JEFFREY PHILIP BOURNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 W JEFFERSON BLVD STE 302
LOS ANGELES CA
90066-7032
US

IV. Provider business mailing address

1811 WILSHIRE BLVD STE 110
SANTA MONICA CA
90403-5626
US

V. Phone/Fax

Practice location:
  • Phone: 424-443-5600
  • Fax: 424-443-5600
Mailing address:
  • Phone: 310-453-9010
  • Fax: 310-828-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME66931
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG86941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: