Healthcare Provider Details

I. General information

NPI: 1871775783
Provider Name (Legal Business Name): MK JEFFERSON MD ANESTHESIA SERVICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD
NORTHRIDGE CA
91325-4105
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-8500
  • Fax:
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG68903C
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG68903C
License Number StateCA

VIII. Authorized Official

Name: MICHAEL K. JEFFERSON
Title or Position: PRESIDENT
Credential: MD
Phone: 818-885-8500