Provider Demographics
NPI:1346411063
Name:JONATHAN JOE, OD A PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:JONATHAN JOE, OD A PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JOE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-468-9622
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0099050Medicaid
CASD0099050Medicaid