Healthcare Provider Details

I. General information

NPI: 1275382855
Provider Name (Legal Business Name): JESSE SHAWN ZUCKERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 12/02/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 BEVERLY BOULEVARD SUITE 101
LOS ANGELES CA
90048
US

IV. Provider business mailing address

8737 BEVERLY BOULEVARD SUITE 101
LOS ANGELES CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 310-289-9224
  • Fax:
Mailing address:
  • Phone: 310-289-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: