Provider Demographics
NPI:1922031806
Name:HUSSAIN, JAMAL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMAL
Middle Name:
Last Name:HUSSAIN
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 3939
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90711-3939
Mailing Address - Country:US
Mailing Address - Phone:602-570-0440
Mailing Address - Fax:
Practice Address - Street 1:3700 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1419
Practice Address - Country:US
Practice Address - Phone:602-570-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52498207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ220808Medicaid
AZ220808Medicaid
AZZ115438Medicare PIN
AZP00473275Medicare PIN