Healthcare Provider Details

I. General information

NPI: 1346294584
Provider Name (Legal Business Name): JAY MICHAEL MASHOUF O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10549 SCRIPPS POWAY PKWY SUITE G
SAN DIEGO CA
92131-3963
US

IV. Provider business mailing address

10549 SCRIPPS POWAY PKWY SUITE G
SAN DIEGO CA
92131-3963
US

V. Phone/Fax

Practice location:
  • Phone: 858-530-2800
  • Fax:
Mailing address:
  • Phone: 858-530-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number10987T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: