Healthcare Provider Details

I. General information

NPI: 1619170222
Provider Name (Legal Business Name): JEREMY K. DEISCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST ROOM 2151
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

PO BOX 1740
LOMA LINDA CA
92354-0240
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-5170
  • Fax:
Mailing address:
  • Phone: 909-558-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberA117116
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberA117116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: