Provider Demographics
NPI:1770028391
Name:FARIAS, JOSE FERNANDO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:FERNANDO
Last Name:FARIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:FERNANDO
Other - Last Name:FARIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5161 POMONA BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1749
Mailing Address - Country:US
Mailing Address - Phone:626-316-0829
Mailing Address - Fax:
Practice Address - Street 1:5161 POMONA BLVD STE 213
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1749
Practice Address - Country:US
Practice Address - Phone:626-316-0829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085U0001X2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound