Provider Demographics
NPI:1073519997
Name:ESTRADA, JAIME (OD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 GAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-1308
Mailing Address - Country:US
Mailing Address - Phone:323-560-2786
Mailing Address - Fax:323-560-2795
Practice Address - Street 1:4511 GAGE AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-1308
Practice Address - Country:US
Practice Address - Phone:323-560-2786
Practice Address - Fax:323-560-2795
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11129T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0111290Medicaid
CAWOP11129AMedicare PIN
CASD0111290Medicaid