Provider Demographics
NPI:1891343463
Name:PUGA, JESUS RICARDO
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:RICARDO
Last Name:PUGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 HOLLISTER ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-1334
Mailing Address - Country:US
Mailing Address - Phone:619-721-7509
Mailing Address - Fax:
Practice Address - Street 1:824 HOLLISTER ST UNIT A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1334
Practice Address - Country:US
Practice Address - Phone:619-721-7509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6557157172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver