Basic Information
| Provider Information | |||||||||
| NPI: | 1366737728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLLEY | ||||||||
| FirstName: | BLAIR | ||||||||
| MiddleName: | MOYLE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13652 CANTARA ST | ||||||||
| Address2: | |||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914025423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183752000 | ||||||||
| FaxNumber: | 8183753201 | ||||||||
| Practice Location | |||||||||
| Address1: | 13652 CANTARA ST | ||||||||
| Address2: | |||||||||
| City: | PANORAMA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914025423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183752000 | ||||||||
| FaxNumber: | 8183753201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2011 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | E5135 | CA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.