Provider Demographics
NPI:1043410871
Name:FERAMISCO, JAMISON DEREK (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMISON
Middle Name:DEREK
Last Name:FERAMISCO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31566 RAILROAD CANYON ROAD
Mailing Address - Street 2:2-130
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9446
Mailing Address - Country:US
Mailing Address - Phone:877-870-9301
Mailing Address - Fax:877-882-0462
Practice Address - Street 1:8898 NAVAJO RD # C-349
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-2141
Practice Address - Country:US
Practice Address - Phone:619-650-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105161208D00000X, 207N00000X
FLME156058208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABU132ZMedicare PIN
CAZZZ15528ZMedicare PIN