Provider Demographics
NPI:1114082021
Name:AL JAWAD, JASIM ALI (MD)
Entity Type:Individual
Prefix:
First Name:JASIM
Middle Name:ALI
Last Name:AL JAWAD
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 1:28661 SUPREME FIELD DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677
Mailing Address - Country:US
Mailing Address - Phone:949-249-9616
Mailing Address - Fax:949-249-9619
Practice Address - Street 1:500 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2831
Practice Address - Country:US
Practice Address - Phone:562-427-1700
Practice Address - Fax:562-427-2116
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53179174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A531790Medicaid
CAFHC80030OtherPROVIDER
CAG02110Medicare UPIN