1366413064 NPI number — JERROD D PAULO OTR/L, CHT

Table of content: JERROD D PAULO OTR/L, CHT (NPI 1366413064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366413064 NPI number — JERROD D PAULO OTR/L, CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAULO
Provider First Name:
JERROD
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, CHT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366413064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13690 E 14TH ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SAN LEANDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94578-2582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-895-5511
Provider Business Mailing Address Fax Number:
510-895-5513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13690 E 14TH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAN LEANDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94578-2582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-895-5511
Provider Business Practice Location Address Fax Number:
510-895-5513
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  OT 2258 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ31058Z . This is a "PROVIDER TRANSACTION ACCESS NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ04670Z . This is a "BLUESHIELD PROVIDER #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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