Provider Demographics
NPI:1366516197
Name:JOHNSRUD, JEFFREY M (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:JOHNSRUD
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 1:1140 W LA VETA AVE
Mailing Address - Street 2:#760
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4223
Mailing Address - Country:US
Mailing Address - Phone:714-541-4442
Mailing Address - Fax:714-835-9550
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:#760
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4223
Practice Address - Country:US
Practice Address - Phone:714-541-4442
Practice Address - Fax:714-835-9550
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51096174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51096Medicare ID - Type Unspecified
ARA51894Medicare UPIN