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General NPI Number Information
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NPI Number | 1609285550
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Entity Type | Individual
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Provider Name | COURTNEY ALEXIS ORYNICH GILLENWATER M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/05/2014
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Last Update Date | 08/05/2014
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Provider Practice Location Address
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Address Line | 1200 N STATE ST IRD 112 LAC USC MEDICAL CENTER PEDIATRICS
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City | LOS ANGELES
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State | CA
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Zip | 90033-1029
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Country | US
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Telephone | 323-226-5700
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Fax |
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Provider Business Mailing Address
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Address Line | 2032 OCEAN PARK BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90405-4914
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Country | US
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Telephone | 561-445-1404
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A131183
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License Number State | CA
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