=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073519997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIME ESTRADA O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2005
-----------------------------------------------------
Last Update Date | 07/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4511 GAGE AVE
-----------------------------------------------------
City | BELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90201-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-560-2786
-----------------------------------------------------
Fax | 323-560-2795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4511 GAGE AVE
-----------------------------------------------------
City | BELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90201-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-560-2786
-----------------------------------------------------
Fax | 323-560-2795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 11129T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------