Provider Demographics
NPI:1427673623
Name:JOSE, ETHAN (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:JOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2024
Mailing Address - Country:US
Mailing Address - Phone:510-386-0823
Mailing Address - Fax:
Practice Address - Street 1:110 COOPER ST # 500
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4574
Practice Address - Country:US
Practice Address - Phone:831-425-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA194810207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine