Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | E3317 | CA |
Y | 222Z00000X | Podiatrist | E3317 | CA |
NPI | 1003866344 |
---|---|
Provider Name | Ronald D. Jensen |
First Address | Modesto, CA 95355-4201 |
Second Address | Modesto, CA 95355-4201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2006 |
Last Update Date | 25/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000E33170 | (05) | CA |
T11631 | (02) | CA |