Healthcare Provider Details

I. General information

NPI: 1922079789
Provider Name (Legal Business Name): SAM M OTSUJI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13313 TELEGRAPH RD
WHITTIER CA
90605-3228
US

IV. Provider business mailing address

13313 TELEGRAPH RD
WHITTIER CA
90605-3228
US

V. Phone/Fax

Practice location:
  • Phone: 562-946-1957
  • Fax: 562-941-6155
Mailing address:
  • Phone: 562-946-1957
  • Fax: 562-941-6155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5194T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: