Basic Information
| Provider Information | |||||||||
| NPI: | 1760560635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 COTNER AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900253303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104452951 | ||||||||
| FaxNumber: | 3104791459 | ||||||||
| Practice Location | |||||||||
| Address1: | 18360 BURBANK BLVD | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913562805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187749080 | ||||||||
| FaxNumber: | 8187749135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3402X | C34888 | CA | Y | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography |
No ID Information.