Healthcare Provider Details

I. General information

NPI: 1073519997
Provider Name (Legal Business Name): JAIME ESTRADA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4511 GAGE AVE
BELL CA
90201-1308
US

IV. Provider business mailing address

4511 GAGE AVE
BELL CA
90201-1308
US

V. Phone/Fax

Practice location:
  • Phone: 323-560-2786
  • Fax: 323-560-2795
Mailing address:
  • Phone: 323-560-2786
  • Fax: 323-560-2795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11129T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: