Healthcare Provider Details

I. General information

NPI: 1134486244
Provider Name (Legal Business Name): IAN TAYLOR MACQUEEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 15TH ST STE 105
SANTA MONICA CA
90404-1810
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-319-4080
  • Fax: 310-394-5215
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA130834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: