Healthcare Provider Details

I. General information

NPI: 1538122106
Provider Name (Legal Business Name): JESUSA AQUINO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1574 W BASE LINE ST SUITE 107
SAN BERNARDINO CA
92411-1736
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax: 909-881-7320
Mailing address:
  • Phone: 909-881-7320
  • Fax: 909-881-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA529660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: