Provider Demographics
NPI:1821272295
Name:JAIRAM, COLIN XEPHARY (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:XEPHARY
Last Name:JAIRAM
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 1:1031 AVENIDA PICO
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6352
Mailing Address - Country:US
Mailing Address - Phone:949-429-1919
Mailing Address - Fax:
Practice Address - Street 1:1031 AVENIDA PICO
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6352
Practice Address - Country:US
Practice Address - Phone:949-429-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101534207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH749ZMedicare PIN