Provider Demographics
NPI:1073865903
Name:JEFFREY S HURLESS DPM A PROFESSIONAL PODIATRY CORPORATION
Entity type:Organization
Organization Name:JEFFREY S HURLESS DPM A PROFESSIONAL PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HURLESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:805-496-2383
Mailing Address - Street 1:425 HAALAND DR STE 201
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5231
Mailing Address - Country:US
Mailing Address - Phone:805-496-2383
Mailing Address - Fax:805-496-2387
Practice Address - Street 1:425 HAALAND DR STE 201
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-5231
Practice Address - Country:US
Practice Address - Phone:805-496-2383
Practice Address - Fax:805-496-2387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4207213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6730420001Medicare NSC