Provider Demographics
NPI:1679758171
Name:PEVSNER, WILLIAM JACOB (DO)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JACOB
Last Name:PEVSNER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:1334 W COVINA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3211
Mailing Address - Country:US
Mailing Address - Phone:909-394-9090
Mailing Address - Fax:909-394-9696
Practice Address - Street 1:1334 W COVINA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3211
Practice Address - Country:US
Practice Address - Phone:909-394-9090
Practice Address - Fax:909-394-9696
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAW20A5383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE08915Medicare UPIN
CAW20A5383BMedicare PIN