Provider Demographics
NPI:1225073190
Name:FINE, JEREMY (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FINE
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 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 1807
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-556-8899
Mailing Address - Fax:310-556-9988
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 1807
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-556-8898
Practice Address - Fax:310-556-8899
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I08037Medicare UPIN