Provider Demographics
NPI:1699779637
Name:WASLEY, JESSE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:WASLEY
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 1:17822 BEACH BLVD,
Mailing Address - Street 2:SUITE 243
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647
Mailing Address - Country:US
Mailing Address - Phone:714-843-9060
Mailing Address - Fax:714-843-0699
Practice Address - Street 1:17822 BEACH BLVD,
Practice Address - Street 2:SUITE 243
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:714-843-9060
Practice Address - Fax:714-843-0699
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42184207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP0014478OtherRAILROAD MEDICARE
CA00A421840Medicaid
CA33-0204047OtherEMPLOYER ID
A85772Medicare UPIN
CA00A421840Medicaid