=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366737728
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAIR MOYLE JOLLEY DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2011
-----------------------------------------------------
Last Update Date | 12/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13652 CANTARA ST
-----------------------------------------------------
City | PANORAMA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91402-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-375-2000
-----------------------------------------------------
Fax | 818-375-3201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13652 CANTARA ST
-----------------------------------------------------
City | PANORAMA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91402-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-375-2000
-----------------------------------------------------
Fax | 818-375-3201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E5135
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------