Provider Demographics
NPI:1043328750
Name:HAWKINS, JEAN GRANT (MD FCCP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:GRANT
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:MD FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18546 ROSCOE BLVD
Mailing Address - Street 2:#308
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-349-2931
Mailing Address - Fax:818-349-7930
Practice Address - Street 1:18546 ROSCOE BLVD
Practice Address - Street 2:#308
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-349-2931
Practice Address - Fax:818-349-7930
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43200207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0005950Medicaid
G43200OtherSTATE LICENSE
00G432000OtherBLUE CROSS BLUE SHIELD
ZZZ90411ZOtherBLUE CROSS BLUE SHIELD GR
CAGR0005950Medicaid
00G432000OtherBLUE CROSS BLUE SHIELD