Provider Demographics
NPI:1972696052
Name:JAIME A ALTAMIRANO M.D., INC.
Entity Type:Organization
Organization Name:JAIME A ALTAMIRANO M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALTAMIRANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-618-3774
Mailing Address - Street 1:15243 VANOWEN ST STE 504A
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3605
Mailing Address - Country:US
Mailing Address - Phone:818-904-0798
Mailing Address - Fax:818-904-0317
Practice Address - Street 1:15243 VANOWEN ST
Practice Address - Street 2:STE 504A
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3605
Practice Address - Country:US
Practice Address - Phone:818-904-0798
Practice Address - Fax:818-904-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A687010Medicaid
CAW20221Medicare PIN