Provider Demographics
NPI:1760417398
Name:WALDURA, JESSICA FOGLER (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FOGLER
Last Name:WALDURA
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 1:2866 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4262
Mailing Address - Country:US
Mailing Address - Phone:415-282-2922
Mailing Address - Fax:
Practice Address - Street 1:2866 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4262
Practice Address - Country:US
Practice Address - Phone:415-282-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA080190993OtherRAILROAD MEDICARE
CA00A738170Medicaid
H72582Medicare UPIN