Healthcare Provider Details

I. General information

NPI: 1700811312
Provider Name (Legal Business Name): EDWARD J JAHNKE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

4100 GUARDIAN ST STE 205
SIMI VALLEY CA
93063-6717
US

V. Phone/Fax

Practice location:
  • Phone: 818-847-6983
  • Fax:
Mailing address:
  • Phone: 805-522-5940
  • Fax: 805-577-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG46668
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: