=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518081652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JPB MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 03/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15243 VANOWEN ST STE 406
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91405-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-780-2106
-----------------------------------------------------
Fax | 818-780-4271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15243 VANOWEN ST STE 406
-----------------------------------------------------
City | VAN NUYS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91405-3636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-780-2106
-----------------------------------------------------
Fax | 818-780-4271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DENISE PHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-780-2106
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------