Provider Demographics
NPI:1255368510
Name:HAMLIN, JEFFERSON ANDREW (MD)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:ANDREW
Last Name:HAMLIN
Suffix:
Gender:M
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:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-445-2983
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-445-2983
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG147892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G147890OtherBLUE SHIELD
CA00G147890Medicaid
CAWG14789VMedicare ID - Type Unspecified
CAWG14789UMedicare ID - Type Unspecified
CAWG14789TMedicare ID - Type Unspecified
CA00G147890Medicaid
CA00G147890OtherBLUE SHIELD