Provider Demographics
NPI:1093707580
Name:QUICENO, JOSE IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:IVAN
Last Name:QUICENO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:865 3RD AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1300
Mailing Address - Country:US
Mailing Address - Phone:619-426-3400
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:SCMG DIVISION OF OPHTHALMOLOGY
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-9108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53660207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF23153Medicare UPIN