Provider Demographics
NPI:1356497655
Name:CUSTODIA, JASON P (DO, MHA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:CUSTODIA
Suffix:
Gender:M
Credentials:DO, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 E OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90022-5113
Mailing Address - Country:US
Mailing Address - Phone:323-725-7372
Mailing Address - Fax:
Practice Address - Street 1:5426 E OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-5113
Practice Address - Country:US
Practice Address - Phone:323-725-7372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry