Provider Demographics
NPI:1134195118
Name:WALI, JYOTIKA L (MD)
Entity type:Individual
Prefix:DR
First Name:JYOTIKA
Middle Name:L
Last Name:WALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E CHAPMAN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-3811
Mailing Address - Country:US
Mailing Address - Phone:714-451-0000
Mailing Address - Fax:714-451-0500
Practice Address - Street 1:1001 E CHAPMAN AVE
Practice Address - Street 2:SUITE D
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3811
Practice Address - Country:US
Practice Address - Phone:714-451-0000
Practice Address - Fax:714-451-0500
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A456290Medicaid
CAEQ451ZOtherMEDICARE ID - GROUP
CAA45629Medicare ID - Type Unspecified
CAE99306Medicare UPIN