Provider Demographics
NPI:1730158197
Name:JAY, SHIRLENE (MD)
Entity type:Individual
Prefix:
First Name:SHIRLENE
Middle Name:
Last Name:JAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 LOMITA BLVD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4909
Mailing Address - Country:US
Mailing Address - Phone:310-257-1988
Mailing Address - Fax:310-257-1897
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:SUITE 503
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4909
Practice Address - Country:US
Practice Address - Phone:310-257-1988
Practice Address - Fax:310-257-1897
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83142207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G831421OtherBLUE SHIELD
CAG83142AMedicare ID - Type Unspecified
CAG83142BMedicare ID - Type Unspecified
CA00G831421OtherBLUE SHIELD
CAG39062Medicare UPIN