Provider Demographics
NPI:1003001009
Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF UNIVERSITY OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PROFESSOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-824-6292
Mailing Address - Street 1:19262 JAMBOREE RD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2502
Mailing Address - Country:US
Mailing Address - Phone:949-824-2343
Mailing Address - Fax:949-824-8737
Practice Address - Street 1:19262 JAMBOREE RD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2502
Practice Address - Country:US
Practice Address - Phone:949-824-2343
Practice Address - Fax:949-824-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12351103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty