Provider Demographics
NPI:1275589962
Name:CERVANTES, JOSE L (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:CERVANTES
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:PO BOX 2705-605
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647
Mailing Address - Country:US
Mailing Address - Phone:562-809-3571
Mailing Address - Fax:562-468-0347
Practice Address - Street 1:1601 N SEPULVEDA BLVD
Practice Address - Street 2:#543
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5111
Practice Address - Country:US
Practice Address - Phone:424-217-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76360207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A763600Medicaid
CA00G812850Medicaid
CAG62692Medicare UPIN
H43889Medicare UPIN
CA00G812850Medicaid
CAWA76360BMedicare PIN