MEDICARE: JACOB B PELTA MD

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	207RR0500X	Rheumatology Physician	G23606	CA

General Provider Information

NPI Number	:	1477664217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB B PELTA MD

Provider Business Mailing Address
First Line	:	6360 WILSHIRE BLVD
Second Line	:	SUITE # 501
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5603
Country	:	US
Telephone Number	:	323-653-6166
Fax Number	:	323-653-6171

Provider Business Practice Location Address
First Line	:	6360 WILSHIRE BLVD
Second Line	:	SUITE # 501
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5603
Country	:	US
Telephone Number	:	323-653-6166
Fax Number	:	323-653-6171

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	10/04/2010

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