Provider Demographics
NPI:1952325268
Name:PERSSELIN, JAY EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:EDWARD
Last Name:PERSSELIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-825-6301
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3633
Practice Address - Fax:310-268-4250
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG44398207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G443980Medicaid
CAWG44398BMedicare PIN
CA00G443980Medicaid