Healthcare Provider Details

I. General information

NPI: 1669778056
Provider Name (Legal Business Name): MAURICIO DE LA LAMA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

400 E 71ST ST 4A
NEW YORK NY
10021-4808
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-6500
  • Fax:
Mailing address:
  • Phone: 312-213-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA121020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: