Basic Information
| Provider Information | |||||||||
| NPI: | 1689610966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAX | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | CHILDRENS' HOSPITAL & HEALTH CENTER - MC 5018 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665832 | ||||||||
| FaxNumber: | 8589666733 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | MAIL CODE 8201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921039001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665832 | ||||||||
| FaxNumber: | 8589666733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | C50120 | CA | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | C50120 | AR | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00C501200 | 05 | CA | MEDICAID |