Healthcare Provider Details

I. General information

NPI: 1245530922
Provider Name (Legal Business Name): JACOB B PELTA MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 WILSHIRE BLVD SUITE # 501
LOS ANGELES CA
90048-5603
US

IV. Provider business mailing address

6360 WILSHIRE BLVD SUITE # 501
LOS ANGELES CA
90048-5603
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-6166
  • Fax: 323-653-6171
Mailing address:
  • Phone: 323-656-3616
  • Fax: 323-653-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG23606
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberG23606
License Number StateCA

VIII. Authorized Official

Name: JACOB B PELTA
Title or Position: OWNER
Credential: MD
Phone: 323-653-6166