Provider Demographics
NPI:1659517654
Name:UC REGENTS UCLA UROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:UC REGENTS UCLA UROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:PROF
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEKERNION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-301-8751
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-301-8708
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:200 MEDICAL PLZ
Practice Address - Street 2:SUITE 365
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-206-1632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-21
Last Update Date:2008-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CAF5519284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No284300000XHospitalsSpecial HospitalGroup - Single Specialty