Provider Demographics
NPI:1437221413
Name:ALVARADO, JORGE A SR (DO)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:A
Last Name:ALVARADO
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:A
Other - Last Name:ALVARADO
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:504 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1120
Mailing Address - Country:US
Mailing Address - Phone:818-247-5910
Mailing Address - Fax:818-247-5919
Practice Address - Street 1:504 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1120
Practice Address - Country:US
Practice Address - Phone:818-247-5910
Practice Address - Fax:818-247-5919
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL74156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ74745ZMedicaid
CA0773020001Medicare NSC