Provider Demographics
NPI:1750510251
Name:D'SA, JENNIFER JOSEPHINE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JOSEPHINE
Last Name:D'SA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:909-428-0170
Mailing Address - Fax:877-778-9312
Practice Address - Street 1:17500 FOOTHILL BLVD
Practice Address - Street 2:#A-2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3798
Practice Address - Country:US
Practice Address - Phone:909-428-0170
Practice Address - Fax:877-778-9312
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2016-09-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA122614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01282961/DU4034OtherRAILROAD MEDICARE-FONTANA
CACA112237Medicare PIN