Provider Demographics
NPI:1073598074
Name:MINOR, JORGE DAMIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:DAMIAN
Last Name:MINOR
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 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #403
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-482-1046
Mailing Address - Fax:213-482-4811
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE #403
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-482-1046
Practice Address - Fax:213-482-4811
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48846174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48846Medicare ID - Type Unspecified
CAC19440Medicare UPIN