Provider Demographics
NPI:1366637449
Name:SHIRLENE JAY, M.D., INC
Entity Type:Organization
Organization Name:SHIRLENE JAY, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE REP
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAVENA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-729-7136
Mailing Address - Street 1:3400 LOMITA BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4909
Mailing Address - Country:US
Mailing Address - Phone:310-257-1988
Mailing Address - Fax:
Practice Address - Street 1:3400 LOMITA BLVD
Practice Address - Street 2:STE 104
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4909
Practice Address - Country:US
Practice Address - Phone:310-257-1988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83142207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21859Medicare PIN