Provider Demographics
NPI:1821033150
Name:PACKER, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:PACKER
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:PO BOX 749421
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-9421
Mailing Address - Country:US
Mailing Address - Phone:310-225-3244
Mailing Address - Fax:310-698-7054
Practice Address - Street 1:101 E. VALENCIA MESA DRIVE
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-992-3907
Practice Address - Fax:714-992-3055
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42128207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G421280Medicaid
CAAS346ZMedicare PIN
CA00G421280Medicaid
CAE78314Medicare UPIN
CAWG42128GMedicare PIN