Healthcare Provider Details

I. General information

NPI: 1164487518
Provider Name (Legal Business Name): THE REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ SUITE 465
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5510
  • Fax: 310-301-8751
Mailing address:
  • Phone: 310-301-8708
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARCIA MORRISSEY
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 310-825-5318