Provider Demographics
NPI:1497078497
Name:SERRANO, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:SERRANO
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 1:2215 W BROADWAY AVE F-211
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804
Mailing Address - Country:US
Mailing Address - Phone:310-738-8018
Mailing Address - Fax:714-533-8078
Practice Address - Street 1:2215 W BROADWAY APT F211
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1354
Practice Address - Country:US
Practice Address - Phone:310-738-8018
Practice Address - Fax:714-533-8078
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8218784172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver