Provider Demographics
NPI:1689601635
Name:SEBAG, JERRY (MD, FACS, FRCOPHTH)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:SEBAG
Suffix:
Gender:M
Credentials:MD, FACS, FRCOPHTH
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:SEBAG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7677 CENTER AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3098
Mailing Address - Country:US
Mailing Address - Phone:714-901-7777
Mailing Address - Fax:714-901-7770
Practice Address - Street 1:7677 CENTER AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3074
Practice Address - Country:US
Practice Address - Phone:714-901-7777
Practice Address - Fax:714-901-7770
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG423623207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G423623OtherMEDI-CAL
CA00G423623OtherMEDI-CAL
CAB74517Medicare UPIN