Provider Demographics
NPI:1023151123
Name:CULVER CITY PEDIATRICS
Entity type:Organization
Organization Name:CULVER CITY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-204-6897
Mailing Address - Street 1:9696 CULVER BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2700
Mailing Address - Country:US
Mailing Address - Phone:310-204-6897
Mailing Address - Fax:
Practice Address - Street 1:9696 CULVER BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2700
Practice Address - Country:US
Practice Address - Phone:310-204-6897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102600Medicaid
CAGR0102600Medicaid