Provider Demographics
NPI:1740214618
Name:APPLEBAUM, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:APPLEBAUM
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 1:17601 17TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1946
Mailing Address - Country:US
Mailing Address - Phone:714-790-0005
Mailing Address - Fax:714-699-2444
Practice Address - Street 1:17601 17TH ST STE 110
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1946
Practice Address - Country:US
Practice Address - Phone:714-790-0005
Practice Address - Fax:714-699-2444
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG054219207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG54219OtherMEDICAL LICENSE
CA00G542191Medicaid
CA05D0896423OtherCLIA
CA05D0896423OtherCLIA
CAA52674Medicare UPIN