Provider Demographics
NPI:1205244738
Name:JAMACHA MEDICAL GROUP INC
Entity type:Organization
Organization Name:JAMACHA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:ANWARUL
Authorized Official - Last Name:AZAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-579-6300
Mailing Address - Street 1:1679 E MAIN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5212
Mailing Address - Country:US
Mailing Address - Phone:619-579-6300
Mailing Address - Fax:619-579-0040
Practice Address - Street 1:1679 E MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5212
Practice Address - Country:US
Practice Address - Phone:619-579-6300
Practice Address - Fax:619-579-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA0052314Medicaid