Healthcare Provider Details

I. General information

NPI: 1184724932
Provider Name (Legal Business Name): KEITH GREGORY HEINZERLING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST STE 540
SANTA MONICA CA
90404-2118
US

IV. Provider business mailing address

1920 COLORADO AVE
SANTA MONICA CA
90404-3414
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7612
  • Fax: 424-277-6342
Mailing address:
  • Phone: 310-319-4700
  • Fax: 310-393-5659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberA79201
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA79201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: