MEDICARE: THE REGENTS OF THE UNIVERSITY OF CALIFORNIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PFY13300	CA

General Provider Information

NPI Number	:	1750698502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE REGENTS OF THE UNIVERSITY OF CALIFORNIA

Provider Business Mailing Address
First Line	:	10880 WILSHIRE BLVD
Second Line	:	SUITE 1800
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4101
Country	:	US
Telephone Number	:	310-794-0619
Fax Number	:	310-794-2808

Provider Business Practice Location Address
First Line	:	10880 WILSHIRE BLVD
Second Line	:	SUITE 1800
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4101
Country	:	US
Telephone Number	:	310-794-0619
Fax Number	:	310-794-2808

Authorized Official
Title or Position	:	PROF. PSYCHIATRY AND BEHAVIORAL SCI
Name	:	MR. STEVEN JOSEPH SHOPTAW
Credential	:	PHD
Telephone Number	:	310-794-6206

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	08/31/2010

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Directions to “THE REGENTS OF THE UNIVERSITY OF CALIFORNIA ” Practice Location

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