Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | DC35196 | CA |
NPI | 1306947429 |
---|---|
Provider Name | Dr. Jaime A Quejada |
First Address | Vista, CA 92083-6227 |
Second Address | Vista, CA 92083-6227 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BQ0897693 | DEA (01) | CA |
DC35196 | LICENSE (01) | CA |