Provider Demographics
NPI:1275797888
Name:HARO, JACQUELINE MARTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARTIN
Last Name:HARO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 CABERNET DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1259
Mailing Address - Country:US
Mailing Address - Phone:310-908-3999
Mailing Address - Fax:
Practice Address - Street 1:1829 CABERNET DR
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1259
Practice Address - Country:US
Practice Address - Phone:310-908-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-12
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010125Medicaid
ILR03049Medicare PIN