Healthcare Provider Details

I. General information

NPI: 1700125127
Provider Name (Legal Business Name): WALTER JAYASINGHE M.D. A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S BEACH BLVD SUITE C
LA HABRA CA
90631-5180
US

IV. Provider business mailing address

200 S BEACH BLVD SUITE C
LA HABRA CA
90631-5180
US

V. Phone/Fax

Practice location:
  • Phone: 562-267-1321
  • Fax: 562-697-3009
Mailing address:
  • Phone: 562-267-1321
  • Fax: 562-697-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA31911
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA31911
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA26210
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20052
License Number StateCA

VIII. Authorized Official

Name: DR. WALTER JAYASINGHE
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 213-483-2620