=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144537218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEMALI BHAKTA JARDOSH O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2010
-----------------------------------------------------
Last Update Date | 03/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 LAKEWOOD CENTER MALL
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-602-6100
-----------------------------------------------------
Fax | 562-295-1520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8016 PRIVET LN
-----------------------------------------------------
City | DOWNEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90241-6011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-208-3332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TA2328
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618002186
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 21424-875
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 14065
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------