Provider Demographics
NPI:1033293592
Name:MARK A. JURY OPTOMETRIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARK A. JURY OPTOMETRIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:JURY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-304-9733
Mailing Address - Street 1:23905 CLINTON KEITH ROAD, SUITE 115
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7899
Mailing Address - Country:US
Mailing Address - Phone:951-304-9733
Mailing Address - Fax:951-304-9734
Practice Address - Street 1:23905 CLINTON KEITH ROAD, SUITE 115
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7899
Practice Address - Country:US
Practice Address - Phone:951-304-9733
Practice Address - Fax:951-304-9734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9583 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0095830Medicaid
CASD0095830Medicaid
CABF301Medicare PIN
CASD0095831Medicare ID - Type Unspecified