Healthcare Provider Details

I. General information

NPI: 1407099633
Provider Name (Legal Business Name): RENE R. S. PACKARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ RONALD REAGAN UCLA MEDICAL CENTER
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

10449 ASHTON AVE UNIT 103
LOS ANGELES CA
90024-5184
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6286
  • Fax:
Mailing address:
  • Phone: 617-671-9018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberA118124
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: