Provider Demographics
NPI:1639662802
Name:BALL, JEREMY (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:BALL
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 1:35430 TRESA LN
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3232
Mailing Address - Country:US
Mailing Address - Phone:951-235-4345
Mailing Address - Fax:
Practice Address - Street 1:1659 E 6TH ST STE A
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223
Practice Address - Country:US
Practice Address - Phone:951-845-0272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33963TLG152W00000X
CAPENDING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty