Provider Demographics
NPI:1245219955
Name:SERNA, JESUS A (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:A
Last Name:SERNA
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 1:2621 S BRISTOL ST
Mailing Address - Street 2:STE 101
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5718
Mailing Address - Country:US
Mailing Address - Phone:714-550-0971
Mailing Address - Fax:714-545-2044
Practice Address - Street 1:2621 S BRISTOL ST
Practice Address - Street 2:STE 101
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5718
Practice Address - Country:US
Practice Address - Phone:714-550-0971
Practice Address - Fax:714-545-2044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C409510Medicaid
CA00C409510Medicaid
CAC40951Medicare ID - Type Unspecified