Provider Demographics
NPI:1689161192
Name:THETFORD, JAY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:THOMAS
Last Name:THETFORD
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 1:14445 OLIVE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1438
Practice Address - Country:US
Practice Address - Phone:760-902-3289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA165159207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine