Provider Demographics
NPI:1306963889
Name:CAM, JIMMY R (LDO)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:R
Last Name:CAM
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 W ARTESIA BLVD
Mailing Address - Street 2:SUITE # 26
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3231
Mailing Address - Country:US
Mailing Address - Phone:310-323-0884
Mailing Address - Fax:
Practice Address - Street 1:1425 W ARTESIA BLVD
Practice Address - Street 2:SUITE # 26
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3231
Practice Address - Country:US
Practice Address - Phone:310-323-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930156FC0801X
CAD6907156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX0037630Medicaid
CAJO18693OtherSPECTERA
CA1399OtherMEDICAL EYE SERVICES
CA112600OtherEYEMED