Provider Demographics
NPI:1487764379
Name:WADA, JERRY KIYOHARU (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:KIYOHARU
Last Name:WADA
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 1:541 W COLORADO ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3640
Mailing Address - Country:US
Mailing Address - Phone:323-254-0046
Mailing Address - Fax:323-488-9782
Practice Address - Street 1:1505 WILSON TER STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4073
Practice Address - Country:US
Practice Address - Phone:818-409-0105
Practice Address - Fax:818-409-0151
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22808207RH0003X
CA47335207RH0000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G228080Medicaid
CAG22808OtherCA MEDICAL LICENSE
CA00G228080Medicaid