Healthcare Provider Details

I. General information

NPI: 1508065020
Provider Name (Legal Business Name): GUADALUPE ANGELICA MEJIA JR. O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MUHAMMAD ALI BLVD
LOUISVILLE KY
40202-1511
US

IV. Provider business mailing address

501 E BROADWAY STE 290
LOUISVILLE KY
40202-2040
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5466
  • Fax: 502-852-4947
Mailing address:
  • Phone: 502-217-8221
  • Fax: 502-217-5056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number007185
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1750DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: