Healthcare Provider Details

I. General information

NPI: 1902112477
Provider Name (Legal Business Name): MELANIE KLEISER LANGFORD O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE JOANNE KLEISER O.D.

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 GENESEE AVE STE. 101
SAN DIEGO CA
92117-4970
US

IV. Provider business mailing address

4310 GENESEE AVE STE. 101
SAN DIEGO CA
92117-4970
US

V. Phone/Fax

Practice location:
  • Phone: 858-560-5181
  • Fax:
Mailing address:
  • Phone: 858-560-5181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 14061 TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: