Healthcare Provider Details

I. General information

NPI: 1689649469
Provider Name (Legal Business Name): MICHAEL JEFFERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TERRACE
GLENDALE CA
91206-4098
US

IV. Provider business mailing address

225 S LAKE AVE #535
PASADENA CA
91101-3010
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8000
  • Fax: 818-546-5632
Mailing address:
  • Phone: 626-204-6734
  • Fax: 626-396-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG68903
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG68903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: