1225357155 NPI number — RANDY HAWKINS, M.D., INC

Table of content: (NPI 1225357155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225357155 NPI number — RANDY HAWKINS, M.D., INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDY HAWKINS, M.D., INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225357155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6709 LA TIJERA BLVD
Provider Second Line Business Mailing Address:
#500
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90045-2017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-674-1970
Provider Business Mailing Address Fax Number:
310-674-7712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
644 E REGENT ST
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-674-1970
Provider Business Practice Location Address Fax Number:
310-674-7712
Provider Enumeration Date:
05/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HAWKINS
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-674-1970

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G49354 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: G49354 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G493540 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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