Healthcare Provider Details

I. General information

NPI: 1255478921
Provider Name (Legal Business Name): JERROLD JAY KARTZINEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 MURRAY GUARD DR STE C
JACKSON TN
38305-3742
US

IV. Provider business mailing address

174 MURRAY GUARD DR STE C
JACKSON TN
38305-3742
US

V. Phone/Fax

Practice location:
  • Phone: 949-398-7654
  • Fax: 949-407-6788
Mailing address:
  • Phone: 949-398-7654
  • Fax: 949-407-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG84196
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number64773
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number46751
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberG84196
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License NumberME 80436
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number80436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: