Provider Demographics
NPI:1477508356
Name:MAZLUMIAN, JORGE R (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:R
Last Name:MAZLUMIAN
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:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-796-4158
Practice Address - Street 1:1690 BARTON RD STE 104
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4230
Practice Address - Country:US
Practice Address - Phone:909-335-0200
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32277208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322770Medicaid
CA00A322770Medicaid