Healthcare Provider Details

I. General information

NPI: 1477005973
Provider Name (Legal Business Name): DORIS BOUDAIE OPTOMETRIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 BEVERLY BLVD
LOS ANGELES CA
90048-6201
US

IV. Provider business mailing address

260 S BEVERLY DR STE 333
BEVERLY HILLS CA
90212-3810
US

V. Phone/Fax

Practice location:
  • Phone: 310-360-3937
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DORIS BOUDAIE
Title or Position: OPTOMETRIST
Credential:
Phone: 310-770-9645