Provider Demographics
NPI:1043398282
Name:DE JAGER, HENDRIK JOHANNES (MD)
Entity type:Individual
Prefix:
First Name:HENDRIK
Middle Name:JOHANNES
Last Name:DE JAGER
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 1:1850 S WATERMAN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2852
Mailing Address - Country:US
Mailing Address - Phone:909-796-2525
Mailing Address - Fax:909-824-2028
Practice Address - Street 1:1850 S WATERMAN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2852
Practice Address - Country:US
Practice Address - Phone:909-796-2525
Practice Address - Fax:909-824-2028
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA252550174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A252550Medicaid
CA00A252550Medicaid
CA00A252550Medicare ID - Type UnspecifiedM-CARE NUMBER