Healthcare Provider Details

I. General information

NPI: 1316172679
Provider Name (Legal Business Name): JANE WADA, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 05/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 MONTROSE AVE SUITE D
MONTROSE CA
91020-1546
US

IV. Provider business mailing address

2103 MONTROSE AVE SUITE D
MONTROSE CA
91020-1546
US

V. Phone/Fax

Practice location:
  • Phone: 818-957-2066
  • Fax: 818-957-0689
Mailing address:
  • Phone: 818-957-2066
  • Fax: 818-957-0689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JANE WADA
Title or Position: OWNER
Credential: M.D.
Phone: 818-957-2066