Provider Demographics
NPI:1720090301
Name:JEROME, DENNIS CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:CARL
Last Name:JEROME
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 1:3801 KATELLA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3338
Mailing Address - Country:US
Mailing Address - Phone:714-892-7735
Mailing Address - Fax:562-594-8832
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3338
Practice Address - Country:US
Practice Address - Phone:714-892-7735
Practice Address - Fax:562-594-8832
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC34461207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35627Medicare UPIN
CAC34461Medicare ID - Type Unspecified