Provider Demographics
NPI:1356480206
Name:BORNSTEIN, JEROME LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:LAWRENCE
Last Name:BORNSTEIN
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 572379
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-2379
Mailing Address - Country:US
Mailing Address - Phone:818-342-9886
Mailing Address - Fax:818-344-2720
Practice Address - Street 1:5170 SEPULVEDA BL.
Practice Address - Street 2:STE. 100
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-784-3878
Practice Address - Fax:818-344-2720
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 28465207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A284650OtherMEDICAL PIN
CAA 83769Medicare UPIN