Healthcare Provider Details

I. General information

NPI: 1982921508
Provider Name (Legal Business Name): WESTSIDE PEDIATRICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
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 Code261Q00000X
TaxonomyClinic/Center
License NumberA102946
License Number StateCA

VIII. Authorized Official

Name: DR. LAWRENCE IAN KAGAN
Title or Position: OWNER
Credential: M.D., F.A.A.P.
Phone: 310-500-5546