Provider Demographics
NPI:1255835989
Name:LOOMIS, KATHERINE AMALIA (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:AMALIA
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N STATE ST.
Mailing Address - Street 2:CLINIC TOWER, SUITE A7D
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:626-318-0152
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE # CHS37121
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1029
Practice Address - Country:US
Practice Address - Phone:626-318-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA164585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA164585OtherMEDICAL LICENSE