Provider Demographics
NPI:1851621312
Name:JONATHAN K. LOO OD, A PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:JONATHAN K. LOO OD, A PROFESSIONAL CORP.
Other - Org Name:JONATHAN K. LOO, O.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LOO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-952-0821
Mailing Address - Street 1:1111 W ROBINHOOD DR
Mailing Address - Street 2:SUITE L
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5626
Mailing Address - Country:US
Mailing Address - Phone:209-952-0821
Mailing Address - Fax:209-952-0825
Practice Address - Street 1:1111 W ROBINHOOD DR
Practice Address - Street 2:SUITE L
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5626
Practice Address - Country:US
Practice Address - Phone:209-952-0821
Practice Address - Fax:209-952-0825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5901TPA152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059010Medicaid
CAT10162Medicare UPIN
CASD0059010Medicaid
CA0619640001Medicare NSC