Provider Demographics
NPI:1093731325
Name:JENSEN, DAVID R (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:R
Last Name:JENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:619 W AVENUE Q
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-3889
Mailing Address - Country:US
Mailing Address - Phone:661-273-2556
Mailing Address - Fax:661-267-4847
Practice Address - Street 1:619 W AVENUE Q
Practice Address - Street 2:SUITE B
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3889
Practice Address - Country:US
Practice Address - Phone:661-273-2556
Practice Address - Fax:661-267-4847
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG44704208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G447040Medicaid
CAA49723Medicare UPIN
CAG44704Medicare ID - Type Unspecified