Provider Demographics
NPI:1386667129
Name:JEON, EDWARD H (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:JEON
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 1:23101 SHERMAN PL
Mailing Address - Street 2:SUITE 405
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2003
Mailing Address - Country:US
Mailing Address - Phone:818-347-3287
Mailing Address - Fax:818-347-2472
Practice Address - Street 1:23101 SHERMAN PL
Practice Address - Street 2:SUITE 405
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-2003
Practice Address - Country:US
Practice Address - Phone:818-347-3287
Practice Address - Fax:818-347-2472
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24941204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A249410Medicaid
CA00A249410OtherBLUE SHIELD
CAA83143Medicare UPIN
CA00A249410OtherBLUE SHIELD
CAA24941Medicare ID - Type UnspecifiedMEDICARE