Healthcare Provider Details

I. General information

NPI: 1619526639
Provider Name (Legal Business Name): TATYANA BUDARINA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 HEALTH CENTER DR STE 403
SAN DIEGO CA
92123-2773
US

IV. Provider business mailing address

10635 CALLE MAR DE MARIPOSA
SAN DIEGO CA
92130-8679
US

V. Phone/Fax

Practice location:
  • Phone: 858-278-9900
  • Fax:
Mailing address:
  • Phone: 626-375-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34342TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number34342TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: