Provider Demographics
NPI:1215075817
Name:JESALVA, ED SANTOS (MD)
Entity type:Individual
Prefix:
First Name:ED
Middle Name:SANTOS
Last Name:JESALVA
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 1:2659 TOWNSGATE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2710
Mailing Address - Country:US
Mailing Address - Phone:805-374-1120
Mailing Address - Fax:805-374-1124
Practice Address - Street 1:2659 TOWNSGATE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2710
Practice Address - Country:US
Practice Address - Phone:805-374-1120
Practice Address - Fax:805-374-1124
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0580632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARZER60515OtherEMC PROVIDER NUMBER
ARZER60515OtherEMC PROVIDER NUMBER
CAW15811Medicare ID - Type Unspecified