Provider Demographics
NPI:1174564710
Name:JASPER, IRWIN L (MD)
Entity type:Individual
Prefix:
First Name:IRWIN
Middle Name:L
Last Name:JASPER
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:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-445-2983
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-445-2983
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA232722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A232720OtherBLUE SHIELD
CA00A232720Medicaid
CAWA23272TMedicare ID - Type Unspecified
WA23272UMedicare ID - Type Unspecified
CAWA23272VMedicare ID - Type Unspecified
CAWA23272QMedicare ID - Type Unspecified
CAWA23272AAMedicare ID - Type Unspecified
CAWA23272PMedicare ID - Type Unspecified
CAWA23272RMedicare ID - Type Unspecified
CAWA23272SMedicare ID - Type Unspecified
CAWA23272WMedicare ID - Type Unspecified
CAWA23272BBMedicare ID - Type Unspecified
CAWA23272ZMedicare ID - Type Unspecified
CA00A232720Medicaid