Healthcare Provider Details

I. General information

NPI: 1679992242
Provider Name (Legal Business Name): JEFFREY RYAN BIRNBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 06/06/2020
Certification Date: 06/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 SUNSET BLVD MAIL STOP 113
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 SUNSET BLVD MAIL STOP 113
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2109
  • Fax:
Mailing address:
  • Phone: 323-361-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56537
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberA167988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: