Provider Demographics
NPI:1740716190
Name:VANDIVER, AMY RUTH
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RUTH
Last Name:VANDIVER
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:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 450
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1233
Practice Address - Country:US
Practice Address - Phone:310-825-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA158695207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology