Healthcare Provider Details

I. General information

NPI: 1811376205
Provider Name (Legal Business Name): DORIS BOUDAIE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 10/20/2016
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: 310-360-3928
Mailing address:
  • Phone: 310-360-3937
  • Fax: 310-360-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10992T
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number10992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: