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General NPI Number Information
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NPI Number | 1639619414
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Entity Type | Organization
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Legal Business Name | LYSANDER JIM, M.D. INC
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Dates
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Enumeration Date | 02/27/2017
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Last Update Date | 02/27/2017
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Provider Practice Location Address
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Address Line | 452 N ALTADENA DR
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City | PASADENA
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State | CA
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Zip | 91107-2536
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Country | US
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Telephone | 626-800-3860
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Fax |
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Provider Business Mailing Address
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Address Line | 601 CAMINO VERDE
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City | S PASADENA
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State | CA
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Zip | 91030-4139
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Country | US
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Telephone | 626-800-3860
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LYSANDER JIM
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Credential | M.D.
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Telephone | 626-800-3860
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 3985886
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License Number State | CA
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