Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | A166142 | CA |
NPI | 1003347808 |
---|---|
Provider Name | Jaime Acosta Berrios |
First Address | Santa Maria, CA 93454-3120 |
Second Address | Santa Maria, CA 93458-2805 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2017 |
Last Update Date | 29/07/2020 |