Provider Demographics
NPI:1336342237
Name:CHARLES A JANSEN, OD, INC
Entity Type:Organization
Organization Name:CHARLES A JANSEN, OD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-678-7100
Mailing Address - Street 1:4000 TYLER ST.
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503
Mailing Address - Country:US
Mailing Address - Phone:951-687-7100
Mailing Address - Fax:951-687-1663
Practice Address - Street 1:4000 TYLER ST.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503
Practice Address - Country:US
Practice Address - Phone:951-687-7100
Practice Address - Fax:951-687-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8158T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA117956Medicare PIN