Provider Demographics
NPI:1407105646
Name:STEPHEN PATT MD, CENTER FOR FAMILY PRACTICE AND ENTERTAINMENT MEDICINE
Entity Type:Organization
Organization Name:STEPHEN PATT MD, CENTER FOR FAMILY PRACTICE AND ENTERTAINMENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-582-1114
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:888W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-582-1114
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:888W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-582-1114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47632A207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG47632AOtherLICENSE