Provider Demographics
NPI:1700811312
Name:JAHNKE, EDWARD J III (MD)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:JAHNKE
Suffix:III
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 1:4100 GUARDIAN ST
Mailing Address - Street 2:STE 205
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-6717
Mailing Address - Country:US
Mailing Address - Phone:805-522-5940
Mailing Address - Fax:805-577-2018
Practice Address - Street 1:501 S BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4809
Practice Address - Country:US
Practice Address - Phone:818-847-6983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG466682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG46668DMedicare PIN
CAA50455Medicare UPIN