Provider Demographics
NPI:1194357038
Name:HAN, JERRY G
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:G
Last Name:HAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 VALLEY CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3530
Mailing Address - Country:US
Mailing Address - Phone:626-696-0390
Mailing Address - Fax:
Practice Address - Street 1:4733 VALLEY CENTER AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3530
Practice Address - Country:US
Practice Address - Phone:626-696-0390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine