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General NPI Number Information
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NPI Number | 1811246747
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Entity Type | Organization
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Legal Business Name | DOUGLAS J NISHIDA, OD, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 09/06/2012
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Last Update Date | 09/06/2012
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Provider Practice Location Address
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Address Line | 13463 WASHINGTON BLVD
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5658
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Country | US
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Telephone | 310-821-8382
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Fax |
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Provider Business Mailing Address
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Address Line | 13463 WASHINGTON BLVD
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5658
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Country | US
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Telephone | 310-821-8382
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DOUG NISHIDA
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Credential | OD
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Telephone | 310-821-8382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 10841T
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License Number State | CA
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