Provider Demographics
NPI:1699851469
Name:ELMORE, JOANN GRACE
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:GRACE
Last Name:ELMORE
Suffix:
Gender:F
Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 420
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8344
Practice Address - Country:US
Practice Address - Phone:310-206-6232
Practice Address - Fax:310-206-3551
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG155516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4373OtherINTERNAL ID-MOTOR VEHICLE ID
WA8186165Medicaid
F55336Medicare UPIN
WAAB25274Medicare PIN
WA8186165Medicaid