Provider Demographics
NPI:1548233059
Name:SO, JIMMY K (OD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:K
Last Name:SO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 W FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8019
Mailing Address - Country:US
Mailing Address - Phone:909-982-9366
Mailing Address - Fax:909-982-2477
Practice Address - Street 1:1261 W FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8019
Practice Address - Country:US
Practice Address - Phone:909-982-9366
Practice Address - Fax:909-982-2477
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10554T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU80466Medicare UPIN