Provider Demographics
NPI:1811376452
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Other - Org Name:UCLA CPN SANTA MONICA BAY PHYSICIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-459-2363
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:400
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:
Practice Address - Street 1:4560 ADMIRALTY WAY
Practice Address - Street 2:100
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5423
Practice Address - Country:US
Practice Address - Phone:310-301-8707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710287297Medicare NSC