Healthcare Provider Details

I. General information

NPI: 1851562318
Provider Name (Legal Business Name): LAWRENCE IAN KAGAN M.D., F.A.A.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 WILSHIRE BLVD STE 120
LOS ANGELES CA
90025-1099
US

IV. Provider business mailing address

12301 WILSHIRE BLVD STE 120
LOS ANGELES CA
90025-1099
US

V. Phone/Fax

Practice location:
  • Phone: 310-500-5546
  • Fax:
Mailing address:
  • Phone: 310-500-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA102946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: