Provider Demographics
NPI:1104824820
Name:JIVRAJKA, VINOD (MD)
Entity Type:Individual
Prefix:
First Name:VINOD
Middle Name:
Last Name:JIVRAJKA
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 1:3621 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3512
Mailing Address - Country:US
Mailing Address - Phone:310-604-0443
Mailing Address - Fax:310-604-3367
Practice Address - Street 1:3621 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 15
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3512
Practice Address - Country:US
Practice Address - Phone:310-604-0443
Practice Address - Fax:310-604-3367
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41517207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A415170Medicaid
CA00A415170Medicare ID - Type Unspecified
CA00A415170Medicaid