=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164569091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY PHILIP BOURNE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 03/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12555 W JEFFERSON BLVD STE 302
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-7032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-443-5600
-----------------------------------------------------
Fax | 424-443-5600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1811 WILSHIRE BLVD STE 110
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-453-9010
-----------------------------------------------------
Fax | 310-828-3661
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME66931
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G86941
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------