Healthcare Provider Details

I. General information

NPI: 1770518714
Provider Name (Legal Business Name): JAY B MADHURE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16281 SAN FERNANDO MISSION BLVD
GRANADA HILLS CA
91344-3725
US

IV. Provider business mailing address

16281 SAN FERNANDO MISSION BLVD
GRANADA HILLS CA
91344-3725
US

V. Phone/Fax

Practice location:
  • Phone: 818-838-4600
  • Fax: 818-366-7479
Mailing address:
  • Phone: 818-838-4600
  • Fax: 818-366-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License NumberA33612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: