Healthcare Provider Details

I. General information

NPI: 1427673623
Provider Name (Legal Business Name): ETHAN JOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 COOPER ST # 500
SANTA CRUZ CA
95060-4574
US

IV. Provider business mailing address

3324 MALIBU DR
SANTA CRUZ CA
95062-2024
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-4100
  • Fax:
Mailing address:
  • Phone: 510-386-0823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA194810
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: