1619152865 NPI number — DR. REBECCA MONROE CANNOM DOESSANT MD

Table of content: DR. REBECCA MONROE CANNOM DOESSANT MD (NPI 1619152865)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619152865 NPI number — DR. REBECCA MONROE CANNOM DOESSANT MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
DOESSANT

Provider First Name:
REBECCA

Provider Middle Name:
MONROE CANNOM

Provider Name Prefix Text:
DR.

Provider Name Suffix Text:

Provider Credential Text:
MD

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
CANNOM

Provider Other First Name:
REBECCA

Provider Other Middle Name:

Provider Other Name Prefix Text:
DR.

Provider Other Name Suffix Text:

Provider Other Credential Text:
MD

Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619152865

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
12/15/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6041 CADILLAC AVE

Provider Second Line Business Mailing Address:
DEPT. OF SURGERY, 3RD FLOOR

Provider Business Mailing Address City Name:
LOS ANGELES

Provider Business Mailing Address State Name:
CA

Provider Business Mailing Address Postal Code:
90034-1702

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
323-857-2968

Provider Business Mailing Address Fax Number:
323-857-3307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N STATE ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
LOS ANGELES

Provider Business Practice Location Address State Name:
CA

Provider Business Practice Location Address Postal Code:
90033-1029

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
323-226-6591

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
01/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 208600000X , with the licence number: A97904 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .