Provider Demographics
NPI:1194243394
Name:JON L SIEMS MD INC
Entity type:Organization
Organization Name:JON L SIEMS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-303-6111
Mailing Address - Street 1:31515 RANCHO PUEBLO RD STE 103
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4837
Mailing Address - Country:US
Mailing Address - Phone:951-303-6111
Mailing Address - Fax:951-302-4448
Practice Address - Street 1:31515 RANCHO PUEBLO RD STE 103
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4837
Practice Address - Country:US
Practice Address - Phone:951-303-6111
Practice Address - Fax:951-302-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54383261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA54383OtherCA MEDICAL LICENSE
CA54383OtherCA MEDICAL LICENSE