Provider Demographics
NPI:1003840869
Name:MINES, JILL SERENE (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:SERENE
Last Name:MINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 LAS POSAS RD
Mailing Address - Street 2:#108
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1501
Mailing Address - Country:US
Mailing Address - Phone:805-484-3331
Mailing Address - Fax:805-484-3331
Practice Address - Street 1:3901 LAS POSAS RD
Practice Address - Street 2:#108
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1501
Practice Address - Country:US
Practice Address - Phone:805-484-3331
Practice Address - Fax:805-484-3331
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG059019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G297660Medicaid
A93527Medicare UPIN
W7092Medicare ID - Type Unspecified