Provider Demographics
NPI:1497982193
Name:JEFFREY K PEARSON A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JEFFREY K PEARSON A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-591-0955
Mailing Address - Street 1:120 CRAVEN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4235
Mailing Address - Country:US
Mailing Address - Phone:760-591-0955
Mailing Address - Fax:760-591-3680
Practice Address - Street 1:120 CRAVEN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4235
Practice Address - Country:US
Practice Address - Phone:760-591-0955
Practice Address - Fax:760-591-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5534207Q00000X
CAA45444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A5534OtherMEDICAL LICENSE
CABY503YOtherMEDICARE PTAN