Provider Demographics
NPI:1922339175
Name:JERROLD DREYER, M.D., INC.
Entity Type:Organization
Organization Name:JERROLD DREYER, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:DREYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-784-3615
Mailing Address - Street 1:4849 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2110
Mailing Address - Country:US
Mailing Address - Phone:818-784-3615
Mailing Address - Fax:818-905-0130
Practice Address - Street 1:4849 VAN NUYS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2110
Practice Address - Country:US
Practice Address - Phone:818-784-3615
Practice Address - Fax:818-905-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G311610Medicaid
CA00G311610Medicaid
CAA44672Medicare UPIN
CACT734AMedicare PIN