Provider Demographics
NPI:1891703989
Name:MOY, JAIME (DO)
Entity Type:Individual
Prefix:MS
First Name:JAIME
Middle Name:
Last Name:MOY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10418 VALLEY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3600
Mailing Address - Country:US
Mailing Address - Phone:626-453-8466
Mailing Address - Fax:
Practice Address - Street 1:2219 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-3901
Practice Address - Country:US
Practice Address - Phone:323-269-0421
Practice Address - Fax:323-780-9432
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8734208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87340Medicaid
CA00AX87340Medicaid