Basic Information
| Provider Information | |||||||||
| NPI: | 1891721353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANTOJA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 666 | ||||||||
| Address2: | |||||||||
| City: | ARTESIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907020666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626344939 | ||||||||
| FaxNumber: | 5626345809 | ||||||||
| Practice Location | |||||||||
| Address1: | 5750 DOWNEY AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907121405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626344939 | ||||||||
| FaxNumber: | 5626345809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | C43031 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00C430310 | 05 | CA | MEDICAID | C43031 | 01 | CA | MEDICAL LICENSE | OTHER |