=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326938135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE O'NEAL ELECTROLOGIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2025
-----------------------------------------------------
Last Update Date | 07/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10123 HAWTHORNE BLVD
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90304-1513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-232-0499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4844 MCCONNELL AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-6712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-232-0499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | L9893
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------