Healthcare Provider Details

I. General information

NPI: 1649441973
Provider Name (Legal Business Name): ANDREA FUMIKO HAWTHORNE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 W SUNSET BLVD PEDIATRICS 5TH FLOOR
LOS ANGELES CA
90027-5969
US

IV. Provider business mailing address

5318 WEST BLVD
LOS ANGELES CA
90043-2416
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-1502
  • Fax:
Mailing address:
  • Phone: 626-260-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A10287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: