Provider Demographics
NPI:1003897075
Name:TWO, JINTAU ERNEST (OP)
Entity Type:Individual
Prefix:
First Name:JINTAU
Middle Name:ERNEST
Last Name:TWO
Suffix:
Gender:M
Credentials:OP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15888 MAIN ST
Mailing Address - Street 2:#112A
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-3452
Mailing Address - Country:US
Mailing Address - Phone:760-949-2242
Mailing Address - Fax:760-949-3131
Practice Address - Street 1:15888 MAIN ST
Practice Address - Street 2:#112A
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3452
Practice Address - Country:US
Practice Address - Phone:760-949-2242
Practice Address - Fax:760-949-3131
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB606T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0086061Medicaid
CASD0086060Medicare ID - Type Unspecified
CASD0086061Medicaid