Provider Demographics
NPI:1477024339
Name:AYALA, JOSE O
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:O
Last Name:AYALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6066 CREST AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-1700
Mailing Address - Country:US
Mailing Address - Phone:951-250-6801
Mailing Address - Fax:
Practice Address - Street 1:6066 CREST AVE APT 5
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-1700
Practice Address - Country:US
Practice Address - Phone:951-250-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
20001200037100OtherMEDICAL