Basic Information
| Provider Information | |||||||||
| NPI: | 1689649469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S LAKE AVE | ||||||||
| Address2: | #535 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911013010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262046734 | ||||||||
| FaxNumber: | 6263960851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 WILSON TERRACE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912064098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184098000 | ||||||||
| FaxNumber: | 8185465632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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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 | 207L00000X | G68903 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | G68903 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G689030 | 05 | CA | MEDICAID |