Healthcare Provider Details

I. General information

NPI: 1225643448
Provider Name (Legal Business Name): JED PADRE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 E SEPULVEDA BLVD
CARSON CA
90745-6323
US

IV. Provider business mailing address

282 E SEPULVEDA BLVD
CARSON CA
90745-6323
US

V. Phone/Fax

Practice location:
  • Phone: 310-518-6861
  • Fax: 310-835-1366
Mailing address:
  • Phone: 310-518-6861
  • Fax: 310-835-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JED PADRE
Title or Position: OWNER
Credential: MD
Phone: 310-518-6861