=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912404492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA CORY FEDEROFF MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 143 N LARCHMONT BLVD FL 2
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90004-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-484-5757
-----------------------------------------------------
Fax | 424-732-5490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9187 CLAIREMONT MESA BLVD STE 6-540
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-894-7380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A164677
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------