Provider Demographics
NPI:1982889622
Name:BLUMBERG, JEREMY MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MATTHEW
Last Name:BLUMBERG
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 140
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8344
Practice Address - Country:US
Practice Address - Phone:310-794-7152
Practice Address - Fax:310-794-1666
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1004792080T0004X, 204F00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2080T0004XAllopathic & Osteopathic PhysiciansPediatricsPediatric Transplant Hepatology
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1982889622Medicaid
CAAT489XMedicare PIN