Provider Demographics
NPI:1295715712
Name:ELIZARES, JACK M (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:ELIZARES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3610 OLD HIGHWAY 53
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9253
Mailing Address - Country:US
Mailing Address - Phone:707-994-8641
Mailing Address - Fax:707-994-5858
Practice Address - Street 1:3610 OLD HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9253
Practice Address - Country:US
Practice Address - Phone:707-994-8641
Practice Address - Fax:707-994-5858
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA6646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066460Medicaid
CA0611210001Medicare NSC
CAT10384Medicare UPIN
CASD0066460Medicaid