Provider Demographics
NPI:1609285550
Name:GILLENWATER, COURTNEY ALEXIS ORYNICH (MD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:ALEXIS ORYNICH
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:ALEXIS
Other - Last Name:ORYNICH (MAIDEN)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2032 OCEAN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4914
Mailing Address - Country:US
Mailing Address - Phone:561-445-1404
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:IRD 112 LAC USC MEDICAL CENTER PEDIATRICS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-226-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA131183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics