Provider Demographics
NPI:1003871914
Name:MARKS, JAY W (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:W
Last Name:MARKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 MT BEACON TER
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-2444
Mailing Address - Country:US
Mailing Address - Phone:323-469-4499
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:SUITE #880
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:323-469-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21318207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G213181Medicaid
CAAY825ZMedicare PIN
A90696Medicare UPIN
CA00G213181Medicaid
WG21318BMedicare ID - Type Unspecified