Healthcare Provider Details

I. General information

NPI: 1942438205
Provider Name (Legal Business Name): ASHLEY G BENNETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY G CLARK M.D.

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS 76
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD MS 76
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 323-669-2113
  • Fax: 323-361-8003
Mailing address:
  • Phone: 323-669-2113
  • Fax: 323-361-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27220
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME113308
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD11684
License Number StateHI
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA121634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: