Provider Demographics
NPI:1518228980
Name:DAVID R JENSEN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DAVID R JENSEN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-273-2556
Mailing Address - Street 1:3011 RANCHO VISTA BLVD
Mailing Address - Street 2:SUITE B-C
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4821
Mailing Address - Country:US
Mailing Address - Phone:661-273-2556
Mailing Address - Fax:661-267-4847
Practice Address - Street 1:3011 RANCHO VISTA BLVD
Practice Address - Street 2:SUITE B-C
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4821
Practice Address - Country:US
Practice Address - Phone:661-273-2556
Practice Address - Fax:661-267-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG044704261QP2300X, 291U00000X, 302F00000X, 302R00000X, 305R00000X, 332BX2000X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No291U00000XLaboratoriesClinical Medical Laboratory
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG044704Medicaid
CAG044704Medicaid