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NPI Code Detail

MEDICARE: MICAH V PAN., O.D.

MEDICARE: MICAH V PAN., O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist

General Provider Information

NPI Number : 1770439630
Entity Type Code : Organization
Provider Name (Legal Business Name) : MICAH V PAN., O.D.
Provider Business Mailing Address
First Line : 15942 LOS SERRANOS COUNTRY CLUB DR STE A
Second Line :
City : CHINO HILLS
State : CA
Zip : 91709-4531
Country : US
Telephone Number : 909-606-9943
Fax Number : 909-606-9118
Provider Business Practice Location Address
First Line : 15942 LOS SERRANOS COUNTRY CLUB DR STE A
Second Line :
City : CHINO HILLS
State : CA
Zip : 91709-4531
Country : US
Telephone Number : 909-606-9943
Fax Number : 909-606-9118
Authorized Official
Title or Position : CEO
Name : LINDA H PAN
Credential :
Telephone Number : 909-472-7959
Provider Enumeration Date : 03/04/2026
Last Update Date : 03/04/2026

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