Provider Demographics
NPI:1871852087
Name:ED S JESALVA MD INC
Entity type:Organization
Organization Name:ED S JESALVA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:SANTOS
Authorized Official - Last Name:JESALVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-374-1120
Mailing Address - Street 1:2659 TOWNSGATE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2710
Mailing Address - Country:US
Mailing Address - Phone:805-374-1120
Mailing Address - Fax:805-374-1124
Practice Address - Street 1:2659 TOWNSGATE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2710
Practice Address - Country:US
Practice Address - Phone:805-374-1120
Practice Address - Fax:805-374-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0580632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1275791980OtherNPI
CAW15811OtherPTAN