Provider Demographics
NPI:1740360742
Name:CABALLERO, JIM ROLAND (OD)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:ROLAND
Last Name:CABALLERO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:ROLAND
Other - Last Name:CABALLERO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:28523 APPLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-4339
Mailing Address - Country:US
Mailing Address - Phone:661-295-9443
Mailing Address - Fax:
Practice Address - Street 1:12661 GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4748
Practice Address - Country:US
Practice Address - Phone:818-367-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8936T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU64442Medicare UPIN