Healthcare Provider Details

I. General information

NPI: 1093211138
Provider Name (Legal Business Name): JEROME DE VERA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 N BRENT ST STE 406
VENTURA CA
93003-2824
US

IV. Provider business mailing address

11234 ANDERSON STREET GME OFFICE WESTERLY SUITE C
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 805-653-6371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number20A17593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: