Provider Demographics
NPI:1457460503
Name:JAYASINGHE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:JAYASINGHE MEDICAL GROUP INC
Other - Org Name:LOS ANGELES MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYASINGHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-2620
Mailing Address - Street 1:1930 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3605
Mailing Address - Country:US
Mailing Address - Phone:213-483-2620
Mailing Address - Fax:213-483-7918
Practice Address - Street 1:319 N SOTO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1837
Practice Address - Country:US
Practice Address - Phone:323-266-6730
Practice Address - Fax:323-266-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207V00000X
CAPA14957363A00000X
CAPA15310363A00000X
CARN349926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0004062Medicaid
CAW8253Medicare ID - Type Unspecified