Provider Demographics
NPI:1508100371
Name:JAGGEN N. BANZAL MD INC
Entity Type:Organization
Organization Name:JAGGEN N. BANZAL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGGEN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BANZAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-478-1101
Mailing Address - Street 1:1455 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1559
Mailing Address - Country:US
Mailing Address - Phone:818-404-7776
Mailing Address - Fax:
Practice Address - Street 1:5540 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4120
Practice Address - Country:US
Practice Address - Phone:323-478-1101
Practice Address - Fax:323-255-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty