Provider Demographics
NPI:1689680092
Name:ALTAMIRANO, JAIME A (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:A
Last Name:ALTAMIRANO
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 1:14900 MAGNOLIA BLVD UNIT 55713
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-7094
Mailing Address - Country:US
Mailing Address - Phone:818-618-3774
Mailing Address - Fax:866-680-4334
Practice Address - Street 1:14900 MAGNOLIA BLVD UNIT 55713
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91413-7094
Practice Address - Country:US
Practice Address - Phone:818-618-3774
Practice Address - Fax:866-680-4334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068701207R00000X, 208M00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A687010Medicaid
CAG96324Medicare UPIN
CA00A687010Medicaid