Provider Demographics
NPI:1093025355
Name:UCLA DEPARTMENT OF PEDIATRIC GROUP PRACTICE
Entity Type:Organization
Organization Name:UCLA DEPARTMENT OF PEDIATRIC GROUP PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:SHERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-825-5095
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:22-474 MDCC
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1752
Mailing Address - Country:US
Mailing Address - Phone:310-825-6196
Mailing Address - Fax:310-825-5834
Practice Address - Street 1:200 MEDICAL PLZ
Practice Address - Street 2:SUITE 265
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-0867
Practice Address - Fax:310-206-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA677319163WP0200X
CA19341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Multi-Specialty