Provider Demographics
NPI:1114981990
Name:LIVINGSTON, EDWARD HARRY (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:HARRY
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:HARDY
Other - Last Name:LEWINSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1304 15TH ST STE 102
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1810
Practice Address - Country:US
Practice Address - Phone:310-319-4080
Practice Address - Fax:310-394-5215
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59396208600000X
TXL9784208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157586201Medicaid
TX8A4886Medicare ID - Type Unspecified
TX157586201Medicaid