Basic Information
| Provider Information | |||||||||
| NPI: | 1699888263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUBY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660520 | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910660520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264470296 | ||||||||
| FaxNumber: | 6266231227 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MISSION BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956422564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092237500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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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 | 207P00000X | G79396 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G793960 | 05 | CA | MEDICAID |