Provider Demographics
NPI:1972565000
Name:NAM, JERRY I (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:I
Last Name:NAM
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 1:4445 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4135
Mailing Address - Country:US
Mailing Address - Phone:951-788-3400
Mailing Address - Fax:951-788-3194
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3400
Practice Address - Fax:979-774-7871
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ66162085N0700X, 2085R0202X
CAA656982085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118679302Medicaid
G72816Medicare UPIN
085350RMedicare ID - Type Unspecified