Healthcare Provider Details

I. General information

NPI: 1639619414
Provider Name (Legal Business Name): LYSANDER JIM, M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 N ALTADENA DR
PASADENA CA
91107-2536
US

IV. Provider business mailing address

601 CAMINO VERDE
S PASADENA CA
91030-4139
US

V. Phone/Fax

Practice location:
  • Phone: 626-800-3860
  • Fax:
Mailing address:
  • Phone: 626-800-3860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3985886
License Number StateCA

VIII. Authorized Official

Name: DR. LYSANDER JIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-800-3860