Provider Demographics
NPI:1437773090
Name:ESPARZA, JOCELYN NUGROHO (DO)
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:NUGROHO
Last Name:ESPARZA
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:PO BOX 50703
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91115-0703
Mailing Address - Country:US
Mailing Address - Phone:323-793-3138
Mailing Address - Fax:
Practice Address - Street 1:5427 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4101
Practice Address - Country:US
Practice Address - Phone:888-499-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTL1342390200000X
CA20A20937390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTL1342OtherOSTEOPATHIC MEDICAL BOARD OF CALIFORNIA