MEDICARE: DR. ETHEL DIJAMCO 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	208D00000X	General Practice Physician	A48307	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	:	1780750752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHEL DIJAMCO MD

Provider Business Mailing Address
First Line	:	PO BOX 10432
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90213-3432
Country	:	US
Telephone Number	:	213-637-2530
Fax Number	:	213-384-3373

Provider Business Practice Location Address
First Line	:	6511 VAN NUYS BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-1425
Country	:	US
Telephone Number	:	818-901-9090
Fax Number	:	818-901-9347

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/09/2007

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