=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154623254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELODY DEBORAH TAVAKOLI O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2010
-----------------------------------------------------
Last Update Date | 02/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5680 BALBOA AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92111-2706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-278-2837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3358
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92163-1358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-516-8753
-----------------------------------------------------
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 | 14039
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------