Provider Demographics
NPI:1114722592
Name:ODRUNIA, JESTER MARK CALLEJO
Entity type:Individual
Prefix:
First Name:JESTER
Middle Name:MARK CALLEJO
Last Name:ODRUNIA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10301 LAKE BRACCIANO AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-8216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5229
Practice Address - Country:US
Practice Address - Phone:694-020-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty