Provider Demographics
NPI:1891721353
Name:PANTOJA, JOSE L (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:PANTOJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 666
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-0666
Mailing Address - Country:US
Mailing Address - Phone:562-634-4939
Mailing Address - Fax:562-634-5809
Practice Address - Street 1:5750 DOWNEY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1405
Practice Address - Country:US
Practice Address - Phone:562-634-4939
Practice Address - Fax:562-634-5809
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43031174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C430310Medicaid
CAC43031OtherMEDICAL LICENSE
CA00C430310Medicaid