Healthcare Provider Details

I. General information

NPI: 1275986127
Provider Name (Legal Business Name): RENE EAPEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

808 W 58TH ST FL 2
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax: 877-720-7181
Mailing address:
  • Phone: 323-541-1600
  • Fax: 323-541-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA162269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: