Provider Demographics
NPI:1649608621
Name:SAN JOSE, RONALDO (LAC)
Entity type:Individual
Prefix:DR
First Name:RONALDO
Middle Name:
Last Name:SAN JOSE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N IRVING BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-1508
Mailing Address - Country:US
Mailing Address - Phone:323-333-4366
Mailing Address - Fax:
Practice Address - Street 1:5544 E 2ND ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-3924
Practice Address - Country:US
Practice Address - Phone:323-333-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15761171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist