Healthcare Provider Details

I. General information

NPI: 1144305574
Provider Name (Legal Business Name): JEREMY ELLIOTT KASLOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N TUSTIN AVE STE 202
SANTA ANA CA
92705-3606
US

IV. Provider business mailing address

720 N TUSTIN AVE STE 202
SANTA ANA CA
92705-3606
US

V. Phone/Fax

Practice location:
  • Phone: 714-565-1032
  • Fax: 714-565-1035
Mailing address:
  • Phone: 714-565-1032
  • Fax: 714-565-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License NumberG55911
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberG55911
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberG55911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: