Basic Information
| Provider Information | |||||||||
| NPI: | 1952368516 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEITZEL | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 512185 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900510185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267753514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 209 FAIR OAKS AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910301814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263962900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | G83409 | CA | N | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 207RH0003X | G83409 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00G834090 | 05 | CA | MEDICAID |