Provider Demographics
NPI:1992752059
Name:JURSON, PHILLIP ANDREW (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ANDREW
Last Name:JURSON
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 1:1600 RIVIERA AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3569
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:3700 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1618
Practice Address - Country:US
Practice Address - Phone:415-719-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG788710207L00000X
CAG78871207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G788710Medicaid
CA00G788710Medicare ID - Type Unspecified
CA00G788710Medicaid