Provider Demographics
NPI:1164572525
Name:AGUILUZ, JACQUELINE BALAYAN (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BALAYAN
Last Name:AGUILUZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21508 NORWALK BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-1122
Mailing Address - Country:US
Mailing Address - Phone:562-868-0733
Mailing Address - Fax:
Practice Address - Street 1:21508 NORWALK BLVD
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-1122
Practice Address - Country:US
Practice Address - Phone:562-868-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX74510Medicaid
CAW20A7451CMedicare ID - Type UnspecifiedMEDICARE HAWIIAN GARDENS