Healthcare Provider Details

I. General information

NPI: 1891268678
Provider Name (Legal Business Name): 17TH STREET OPTOMETRY APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 17TH ST STE M
TUSTIN CA
92780-1955
US

IV. Provider business mailing address

17300 17TH ST STE M
TUSTIN CA
92780-1955
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-9664
  • Fax: 714-838-6774
Mailing address:
  • Phone: 714-838-9664
  • Fax: 714-838-6774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER ELSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 949-338-7027