Healthcare Provider Details

I. General information

NPI: 1093025355
Provider Name (Legal Business Name): UCLA DEPARTMENT OF PEDIATRIC GROUP PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ SUITE 265
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

10833 LE CONTE AVE 22-474 MDCC
LOS ANGELES CA
90095-1752
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-0867
  • Fax: 310-206-5146
Mailing address:
  • Phone: 310-825-6196
  • Fax: 310-825-5834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number677319
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19341
License Number StateCA

VIII. Authorized Official

Name: SHERIN DEVASKAR
Title or Position: INTERIM EXECUTIVE CHAIR
Credential: MD
Phone: 310-825-5095