Provider Demographics
NPI:1982609590
Name:SOARES, TRAJAN JOAQUIN (OD)
Entity Type:Individual
Prefix:DR
First Name:TRAJAN
Middle Name:JOAQUIN
Last Name:SOARES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4218
Mailing Address - Country:US
Mailing Address - Phone:209-826-1434
Mailing Address - Fax:209-826-8375
Practice Address - Street 1:1028 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4218
Practice Address - Country:US
Practice Address - Phone:209-826-1434
Practice Address - Fax:209-826-8375
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9569TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0095690Medicaid
CAU19842Medicare UPIN
CASD0095690Medicaid