Healthcare Provider Details

I. General information

NPI: 1780694125
Provider Name (Legal Business Name): JEREMY EVAN ENSOR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 LAFAYETTE CIR
LAFAYETTE CA
94549-4379
US

IV. Provider business mailing address

284 LAFAYETTE CIR
LAFAYETTE CA
94549-4379
US

V. Phone/Fax

Practice location:
  • Phone: 925-284-1500
  • Fax:
Mailing address:
  • Phone: 925-284-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: