Provider Demographics
NPI:1376839449
Name:WOLOSZYN, JAKUB (MD)
Entity Type:Individual
Prefix:
First Name:JAKUB
Middle Name:
Last Name:WOLOSZYN
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 1:25865 BARTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3896
Mailing Address - Country:US
Mailing Address - Phone:214-729-7191
Mailing Address - Fax:
Practice Address - Street 1:11175 CAMPUS ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1700
Practice Address - Country:US
Practice Address - Phone:909-558-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA77814204F00000X
390200000X
CAA124914208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN