MEDICARE: DR. JACK EDWARD LAMENDOLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	00A37053	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053345959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK EDWARD LAMENDOLA M.D.

Provider Business Mailing Address
First Line	:	7248 S LAND PARK DR
Second Line	:	SUITE 113
City	:	SACRAMENTO
State	:	CA
Zip	:	95831-3660
Country	:	US
Telephone Number	:	916-395-5226
Fax Number	:	916-399-1569

Provider Business Practice Location Address
First Line	:	7248 S LAND PARK DR
Second Line	:	SUITE 113
City	:	SACRAMENTO
State	:	CA
Zip	:	95831-3660
Country	:	US
Telephone Number	:	916-395-5226
Fax Number	:	916-399-1569

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/09/2007

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