Basic Information
| Provider Information | |||||||||
| NPI: | 1780870899 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NO 54826 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884864340 | ||||||||
| FaxNumber: | 5629245830 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921039001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195436222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHAN | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6195436463 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0069870 | 05 | CA | MEDICAID |