Healthcare Provider Details

I. General information

NPI: 1487764379
Provider Name (Legal Business Name): JERRY KIYOHARU WADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER STE 200
GLENDALE CA
91206-4073
US

IV. Provider business mailing address

541 W COLORADO ST STE 205
GLENDALE CA
91204-3640
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-0105
  • Fax: 818-409-0151
Mailing address:
  • Phone: 323-254-0046
  • Fax: 323-488-9782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberG22808
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: