Provider Demographics
NPI:1679590566
Name:AL-JAZAYRLY, GHASSAN (MD)
Entity Type:Individual
Prefix:
First Name:GHASSAN
Middle Name:
Last Name:AL-JAZAYRLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012-0006
Mailing Address - Country:US
Mailing Address - Phone:323-660-6200
Mailing Address - Fax:323-660-6212
Practice Address - Street 1:1300 N VERMONT AVE # 606
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-660-6200
Practice Address - Fax:323-660-6212
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52470207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A524700Medicaid
CAG15882Medicare UPIN
CAA52470Medicare ID - Type Unspecified