Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | B606T | CA |
NPI | 1003897075 |
---|---|
Provider Name | Jintau Ernest Two |
First Address | Hesperia, CA 92345-3452 |
Second Address | Hesperia, CA 92345-3452 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
SD0086061 | (05) | CA |
U09096 | (02) |