Provider Demographics
NPI:1255380606
Name:SKYDELL, JAMES LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LAWRENCE
Last Name:SKYDELL
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 1:2428 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE L.L.
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2045
Mailing Address - Country:US
Mailing Address - Phone:310-315-0212
Mailing Address - Fax:
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:SUITE L.L.
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG495522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G495520Medicaid
CAG49552Medicare ID - Type Unspecified
CA00G495520Medicaid