Healthcare Provider Details

I. General information

NPI: 1144369372
Provider Name (Legal Business Name): MARY MCMAINS OD MED AN OPTOMETRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 4TH AVE
SAN DIEGO CA
92103-5703
US

IV. Provider business mailing address

3355 4TH AVE
SAN DIEGO CA
92103-5703
US

V. Phone/Fax

Practice location:
  • Phone: 619-229-9767
  • Fax: 619-692-0747
Mailing address:
  • Phone: 619-229-9767
  • Fax: 619-692-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number11525T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number11525T
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number11525T
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number11525T
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number11525T
License Number StateCA

VIII. Authorized Official

Name: MARY MCMAINS
Title or Position: PRESIDENT
Credential: OD
Phone: 619-229-9767