Provider Demographics
NPI:1982759114
Name:SELAM, JEAN LOUIS
Entity Type:Individual
Prefix:DR
First Name:JEAN LOUIS
Middle Name:
Last Name:SELAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2492 WALNUT AVE
Mailing Address - Street 2:SUITE # 130
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6953
Mailing Address - Country:US
Mailing Address - Phone:714-734-7944
Mailing Address - Fax:714-734-7945
Practice Address - Street 1:2492 WALNUT AVE
Practice Address - Street 2:SUITE # 130
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6953
Practice Address - Country:US
Practice Address - Phone:714-734-7944
Practice Address - Fax:714-734-7945
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW809FMedicare ID - Type UnspecifiedEL MONTE
CAW809BMedicare ID - Type UnspecifiedHUDSON
CAW809AMedicare ID - Type UnspecifiedROYBAL
CAW932Medicare ID - Type UnspecifiedHEALTH CENTER