Provider Demographics
NPI:1760412811
Name:JAMESON, JAMES LARRY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LARRY
Last Name:JAMESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:LARRY
Other - Last Name:JAMESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3400 CIVIC CENTER BOULEVARD
Mailing Address - Street 2:WEST PAVILION, 4TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5134
Mailing Address - Country:US
Mailing Address - Phone:215-662-2300
Mailing Address - Fax:215-614-0418
Practice Address - Street 1:3400 CIVIC CENTER BOULEVARD
Practice Address - Street 2:WEST PAVILION, 4TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5134
Practice Address - Country:US
Practice Address - Phone:215-662-2300
Practice Address - Fax:215-614-0418
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086440207RE0101X
PAMD442697207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
B98067Medicare UPIN