Healthcare Provider Details

I. General information

NPI: 1417538257
Provider Name (Legal Business Name): ADAM HULISZ O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 DEAUVILLE PL
COSTA MESA CA
92626-2628
US

IV. Provider business mailing address

1452 DEAUVILLE PL
COSTA MESA CA
92626-2628
US

V. Phone/Fax

Practice location:
  • Phone: 714-393-8291
  • Fax:
Mailing address:
  • Phone: 714-393-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12308060-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: