Provider Demographics
NPI:1518164706
Name:KOOLWIJK, IRENE (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KOOLWIJK
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 1:5767 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:310-301-8707
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:300 UCLA MEDICAL PLZ STE 3300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6062
Practice Address - Country:US
Practice Address - Phone:310-825-0867
Practice Address - Fax:310-206-4855
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA121627208000000X, 2080P0008X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities