Provider Demographics
NPI:1679123061
Name:ERAZO, JORGE A
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:A
Last Name:ERAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 W MERCED AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3404
Mailing Address - Country:US
Mailing Address - Phone:909-525-2280
Mailing Address - Fax:626-337-7087
Practice Address - Street 1:1535 W MERCED AVE STE 104
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3404
Practice Address - Country:US
Practice Address - Phone:626-337-7087
Practice Address - Fax:626-337-7089
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty