Healthcare Provider Details

I. General information

NPI: 1700713195
Provider Name (Legal Business Name): JSK PREMIER MSO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 N HARBOR BLVD STE 350
FULLERTON CA
92835-2602
US

IV. Provider business mailing address

17 BARLETT PL
TUSTIN CA
92782-3742
US

V. Phone/Fax

Practice location:
  • Phone: 714-529-8923
  • Fax:
Mailing address:
  • Phone: 909-631-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084H0002X
TaxonomyHospice and Palliative Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHISH BHAVSAR
Title or Position: CEO
Credential: MD
Phone: 909-631-8521