Healthcare Provider Details

I. General information

NPI: 1962886887
Provider Name (Legal Business Name): JUSTINE SIMON BAILEY OD, FCOVD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 VILLA LA JOLLA DR STE B128
LA JOLLA CA
92037-1705
US

IV. Provider business mailing address

8950 VILLA LA JOLLA DR STE B128
LA JOLLA CA
92037-1705
US

V. Phone/Fax

Practice location:
  • Phone: 408-406-7334
  • Fax:
Mailing address:
  • Phone: 408-406-7334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number56 008342
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number33596
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: