Provider Demographics
NPI:1710159447
Name:DASCALOS, JANE (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:DASCALOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 16TH ST STE 100
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1255
Practice Address - Country:US
Practice Address - Phone:310-301-6800
Practice Address - Fax:310-794-9035
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA887282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A887280OtherBLUE SHIELD
CA00A887280Medicaid
CA1710159447Medicaid
CAWA88728BMedicare PIN
CA00A887280OtherBLUE SHIELD
CABZ611ZMedicare PIN
CABZ611YMedicare PIN