Provider Demographics
NPI:1588778971
Name:JANSEN, CHARLES ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALAN
Last Name:JANSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3402
Mailing Address - Country:US
Mailing Address - Phone:951-687-7100
Mailing Address - Fax:951-687-1663
Practice Address - Street 1:4000 TYLER ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3402
Practice Address - Country:US
Practice Address - Phone:951-687-7100
Practice Address - Fax:951-687-1663
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8158152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081580Medicaid
CASD0081580Medicare ID - Type Unspecified
CASD0081580Medicaid