Provider Demographics
NPI:1740511369
Name:CAMILO S JORGE M.D. PROF CORP
Entity type:Organization
Organization Name:CAMILO S JORGE M.D. PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:JORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-531-1946
Mailing Address - Street 1:16415 COLORADO AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5035
Mailing Address - Country:US
Mailing Address - Phone:562-531-1946
Mailing Address - Fax:562-531-1010
Practice Address - Street 1:16415 COLORADO AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5035
Practice Address - Country:US
Practice Address - Phone:562-531-1946
Practice Address - Fax:562-531-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA18393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A183931Medicaid
CA1215028238OtherNPI
CA00A183931Medicaid