Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | C43174 | CA |
N | 208000000X | Pediatrician | C43174 | CA |
NPI | 1255548327 |
---|---|
Provider Name | Jose Camacho |
First Address | Del Mar, CA 92014-0495 |
Second Address | West Covina, CA 91790-5061 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 27/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00C431740 | (05) | CA |
F74581 | (02) | CA |