Healthcare Provider Details

I. General information

NPI: 1215015847
Provider Name (Legal Business Name): JAY I. LA BOURENE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550-G TIBURON BLVD
TIBURON CA
94920
US

IV. Provider business mailing address

1550 TIBURON BLVD STE G
TIBURON CA
94920-2531
US

V. Phone/Fax

Practice location:
  • Phone: 415-833-2000
  • Fax:
Mailing address:
  • Phone: 415-833-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG79536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: