Healthcare Provider Details

I. General information

NPI: 1194103622
Provider Name (Legal Business Name): MARIA EUGENIA SANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2015
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 CLARK ST
TARZANA CA
91356-3501
US

IV. Provider business mailing address

3701 WILSHIRE BLVD STE 600
LOS ANGELES CA
90010-2814
US

V. Phone/Fax

Practice location:
  • Phone: 818-881-0800
  • Fax:
Mailing address:
  • Phone: 323-361-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA52275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: