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General NPI Number Information
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NPI Number | 1366782922
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Entity Type | Individual
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Provider Name | JOTHAN STALEY M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/19/2013
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Last Update Date | 02/19/2013
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Provider Practice Location Address
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Address Line | 140 W QUEEN ST
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City | INGLEWOOD
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State | CA
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Zip | 90301-1726
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Country | US
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Telephone | 323-357-4225
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Fax |
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Provider Business Mailing Address
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Address Line | 140 W QUEEN ST
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City | INGLEWOOD
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State | CA
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Zip | 90301-1726
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Country | US
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Telephone | 323-357-4225
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | G36886
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2083P0500X
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Taxonomy Name | Preventive Medicine/Occupational Environmental Medicine Physician
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License Number | G36886
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License Number State | CA
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