Provider Demographics
NPI:1083912869
Name:CHANNICK, JAY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:MICHAEL
Last Name:CHANNICK
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 1:821 B AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2615
Mailing Address - Country:US
Mailing Address - Phone:619-435-4794
Mailing Address - Fax:
Practice Address - Street 1:821 B AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-2615
Practice Address - Country:US
Practice Address - Phone:619-435-4794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16554207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology