Healthcare Provider Details

I. General information

NPI: 1518228980
Provider Name (Legal Business Name): DAVID R JENSEN MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 RANCHO VISTA BLVD SUITE B-C
PALMDALE CA
93551-4821
US

IV. Provider business mailing address

3011 RANCHO VISTA BLVD SUITE B-C
PALMDALE CA
93551-4821
US

V. Phone/Fax

Practice location:
  • Phone: 661-273-2556
  • Fax: 661-267-4847
Mailing address:
  • Phone: 661-273-2556
  • Fax: 661-267-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberG044704
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberG044704
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberG044704
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberG044704
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberG044704
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberG044704
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberG044704
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID RICHARD JENSEN
Title or Position: OWNER
Credential: M.D.
Phone: 661-273-2556