Provider Demographics
NPI:1659460897
Name:VIRGIN, JEFFREY BOB (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BOB
Last Name:VIRGIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2374 E PACIFICA PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO DOMINGUEZ
Mailing Address - State:CA
Mailing Address - Zip Code:90220-6214
Mailing Address - Country:US
Mailing Address - Phone:310-225-3244
Mailing Address - Fax:310-698-7040
Practice Address - Street 1:2374 E PACIFICA PL
Practice Address - Street 2:
Practice Address - City:RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90220-6214
Practice Address - Country:US
Practice Address - Phone:310-225-3244
Practice Address - Fax:310-698-7040
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028232207ZP0101X
CAG156025207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659460897Medicaid