Provider Demographics
NPI:1255479408
Name:KIDDOX MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:KIDDOX MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-453-9010
Mailing Address - Street 1:1245 16TH ST
Mailing Address - Street 2:#305
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1235
Mailing Address - Country:US
Mailing Address - Phone:310-453-9010
Mailing Address - Fax:310-828-3661
Practice Address - Street 1:1245 16TH ST
Practice Address - Street 2:#305
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1235
Practice Address - Country:US
Practice Address - Phone:310-453-9010
Practice Address - Fax:310-828-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24539208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty