Provider Demographics
NPI:1396835153
Name:JOSEPH, JAY SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:SAMUEL
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1165 S DORA ST BLDG H
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-8325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1165 S DORA ST BLDG H
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-8325
Practice Address - Country:US
Practice Address - Phone:707-463-3636
Practice Address - Fax:707-463-2714
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG747992085R0203X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G747990Medicaid
F49628Medicare UPIN
00G747990Medicare ID - Type Unspecified