Provider Demographics
NPI:1215015847
Name:LA BOURENE, JAY I (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:I
Last Name:LA BOURENE
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 1:1550 TIBURON BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2531
Mailing Address - Country:US
Mailing Address - Phone:415-833-2000
Mailing Address - Fax:
Practice Address - Street 1:1550-G TIBURON BLVD
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920
Practice Address - Country:US
Practice Address - Phone:415-833-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79536208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225508385OtherNPI-TYPE 2
CA00G795360Medicaid
00G795360Medicare ID - Type Unspecified