Provider Demographics
NPI:1053632430
Name:CHAMPAGNE, PHILIPPE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIPPE
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 16TH ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1235
Mailing Address - Country:US
Mailing Address - Phone:310-315-8900
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ STE 7501
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1736
Practice Address - Country:US
Practice Address - Phone:310-825-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-19
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119139207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics