Provider Demographics
NPI:1619995800
Name:ANAYA, JUAN PABLO (OD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:ANAYA
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 1:14240 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3328
Mailing Address - Country:US
Mailing Address - Phone:510-232-3060
Mailing Address - Fax:510-232-0377
Practice Address - Street 1:14240 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3328
Practice Address - Country:US
Practice Address - Phone:510-232-3060
Practice Address - Fax:510-232-0377
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12274T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0012274Medicaid
CAMA1002409OtherDEA #
CASD0122740Medicare ID - Type Unspecified
CAU97153Medicare UPIN