Basic Information
Provider Information | |||||||||
NPI: | 1770796708 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLE | ||||||||
FirstName: | CHRISTINE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 267 W HILLCREST DR | ||||||||
Address2: |   | ||||||||
City: | THOUSAND OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 913604211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054971694 | ||||||||
FaxNumber: | 8053737493 | ||||||||
Practice Location | |||||||||
Address1: | 267 W HILLCREST DR | ||||||||
Address2: |   | ||||||||
City: | THOUSAND OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 91360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054971694 | ||||||||
FaxNumber: | 8053737493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2007 | ||||||||
LastUpdateDate: | 05/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 40609 | AZ | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207ND0900X | A119802 | CA | N |   | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | MD444035 | PA | N |   | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207N00000X | A119802 | CA | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 354255 | 05 | AZ |   | MEDICAID | P01125198 | 01 | CA | RAILROAD MEDICARE | OTHER | GK137Z | 05 | CA |   | MEDICAID | P00623799 | 01 | AZ | RAILROAD MEDICARE | OTHER |