Healthcare Provider Details

I. General information

NPI: 1205558988
Provider Name (Legal Business Name): MIGUEL OLMEDO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7862 BARBI LN
LA PALMA CA
90623-1603
US

IV. Provider business mailing address

7862 BARBI LN
LA PALMA CA
90623-1603
US

V. Phone/Fax

Practice location:
  • Phone: 562-405-7309
  • Fax:
Mailing address:
  • Phone: 562-405-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: