Provider Demographics
NPI:1124213988
Name:JEAN T MIYASHITA MD
Entity Type:Organization
Organization Name:JEAN T MIYASHITA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIYASHITA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-343-1700
Mailing Address - Street 1:18411 CLARK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3527
Mailing Address - Country:US
Mailing Address - Phone:818-343-1700
Mailing Address - Fax:818-343-1738
Practice Address - Street 1:18411 CLARK ST STE 103
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3527
Practice Address - Country:US
Practice Address - Phone:818-343-1700
Practice Address - Fax:818-343-1738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79761261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG79761Medicare PIN
CAG59120Medicare UPIN