1699300731 NPI number — SIMONE NICOLE BOECKMANN MONTGOMERY MD, MPH

Table of content: SIMONE NICOLE BOECKMANN MONTGOMERY MD, MPH (NPI 1699300731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699300731 NPI number — SIMONE NICOLE BOECKMANN MONTGOMERY MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
SIMONE
Provider Middle Name:
NICOLE BOECKMANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MPH
Provider Gender Code:
F

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:
1699300731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N STATE ST RM 3250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90089-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-409-3360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N STATE STREET
Provider Second Line Business Practice Location Address:
GENERAL HOSPITAL, DERMATOLOGY - RM 3250
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-409-3360
Provider Business Practice Location Address Fax Number:
323-226-2654
Provider Enumeration Date:
03/09/2020

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: A180644 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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