Provider Demographics
NPI:1265470694
Name:LAWRENCE J JAFFE MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LAWRENCE J JAFFE MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:JAFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-233-1616
Mailing Address - Street 1:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:619-233-1616
Mailing Address - Fax:
Practice Address - Street 1:4411 MORENA BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-4328
Practice Address - Country:US
Practice Address - Phone:619-233-1616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA322742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322740Medicaid
CA00A322740Medicaid