Healthcare Provider Details

I. General information

NPI: 1558479147
Provider Name (Legal Business Name): JERRY JUDD PRYDE JR. MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S. FLOWER ST #412
LOS ANGELES CA
90015-2144
US

IV. Provider business mailing address

1130 S. FLOWER ST #412
LOS ANGELES CA
90015-2144
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-2182
  • Fax: 213-403-4373
Mailing address:
  • Phone: 310-423-2182
  • Fax: 213-403-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA060849
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: