Provider Demographics
NPI:1245530922
Name:JACOB B PELTA MD
Entity type:Organization
Organization Name:JACOB B PELTA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:B
Authorized Official - Last Name:PELTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-653-6166
Mailing Address - Street 1:6360 WILSHIRE BLVD
Mailing Address - Street 2:SUITE # 501
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5603
Mailing Address - Country:US
Mailing Address - Phone:323-656-3616
Mailing Address - Fax:323-653-6171
Practice Address - Street 1:6360 WILSHIRE BLVD
Practice Address - Street 2:SUITE # 501
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5603
Practice Address - Country:US
Practice Address - Phone:323-653-6166
Practice Address - Fax:323-653-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23606207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty