Healthcare Provider Details

I. General information

NPI: 1588079925
Provider Name (Legal Business Name): REBECCA MARTINEZ-HANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # MS 31
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD # 31
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-6596
  • Fax: 323-361-1303
Mailing address:
  • Phone: 323-361-6596
  • Fax: 233-613-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014019007
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: