Healthcare Provider Details

I. General information

NPI: 1578833059
Provider Name (Legal Business Name): JSMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LORTON AVENUE
BURLINGAME CA
94010-4104
US

IV. Provider business mailing address

PO BOX 117627
BURLINGAME CA
94011-7627
US

V. Phone/Fax

Practice location:
  • Phone: 650-241-6508
  • Fax: 925-482-1195
Mailing address:
  • Phone: 650-241-6508
  • Fax: 925-482-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberA66219
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN E. BOURKE
Title or Position: CO-FOUNDER AND MEDICAL DIRECTOR
Credential: M.D.
Phone: 650-241-6508