=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609148956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY S.H. MASSERMAN, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2012
-----------------------------------------------------
Last Update Date | 02/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11180 WARNER AVE. SUITE #455
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-556-0536
-----------------------------------------------------
Fax | 714-435-9640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11180 WARNER AVENUE SUITE 455
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-556-0536
-----------------------------------------------------
Fax | 714-435-9640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAY S.H. MASSERMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-556-0536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------