Provider Demographics
NPI:1558479147
Name:PRYDE, JERRY JUDD JR (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JUDD
Last Name:PRYDE
Suffix:JR
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 S. FLOWER ST #412
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2144
Mailing Address - Country:US
Mailing Address - Phone:310-423-2182
Mailing Address - Fax:213-403-4373
Practice Address - Street 1:1130 S. FLOWER ST #412
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-2144
Practice Address - Country:US
Practice Address - Phone:310-423-2182
Practice Address - Fax:213-403-4373
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA060849208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG96316Medicare UPIN