MEDICARE: JOSHUA JORDAN MEDICAL CORPORATION

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	207R00000X	Internal Medicine Physician	20A10231	CA

General Provider Information

NPI Number	:	1295034395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSHUA JORDAN MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 27851
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92809-0128
Country	:	US
Telephone Number	:	714-262-5136
Fax Number	:	310-499-5261

Provider Business Practice Location Address
First Line	:	3275 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-4348
Country	:	US
Telephone Number	:	714-262-5136
Fax Number	:	310-499-5261

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROYA MASOUD
Credential	:	DO
Telephone Number	:	714-262-5136

Provider Enumeration Date	:	03/15/2011
Last Update Date	:	06/27/2011

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