Provider Demographics
NPI:1417119231
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Other - Org Name:AESTHETIC & PLASTIC SURGERY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-6655
Mailing Address - Street 1:PO BOX 515072
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5072
Mailing Address - Country:US
Mailing Address - Phone:714-456-6655
Mailing Address - Fax:714-456-2280
Practice Address - Street 1:200 S MANCHESTER AVE
Practice Address - Street 2:STE 650
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3224
Practice Address - Country:US
Practice Address - Phone:714-456-6655
Practice Address - Fax:714-456-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57437208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty