Healthcare Provider Details

I. General information

NPI: 1568501120
Provider Name (Legal Business Name): WALT JAY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 WILSHIRE BLVD SUITE 600
LOS ANGELES CA
90057-3605
US

IV. Provider business mailing address

318 N 3RD ST
ALHAMBRA CA
91801-2387
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9902
  • Fax: 213-483-5174
Mailing address:
  • Phone: 626-943-7848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA23961
License Number StateCA

VIII. Authorized Official

Name: MRS. SHERINE GANEGODA
Title or Position: OFFICE MANAGER'S ASSISTANT
Credential:
Phone: 213-483-9902