Provider Demographics
NPI:1316036908
Name:JOE, JONATHAN JAMES (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAMES
Last Name:JOE
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 1:20687 AMAR RD STE 6
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-5045
Mailing Address - Country:US
Mailing Address - Phone:909-468-9622
Mailing Address - Fax:909-468-9230
Practice Address - Street 1:20687 AMAR RD STE 6
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-5045
Practice Address - Country:US
Practice Address - Phone:909-468-9622
Practice Address - Fax:909-468-9230
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 9905 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD 0099050Medicaid
CAOP9905Medicare ID - Type Unspecified
CASD 0099050Medicaid