MEDICARE: LAKE MERRITT OPTOMETRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	11844T	CA

General Provider Information

NPI Number	:	1134515679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE MERRITT OPTOMETRY

Provider Business Mailing Address
First Line	:	1807 3RD AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94606-1803
Country	:	US
Telephone Number	:	510-444-1969
Fax Number	:

Provider Business Practice Location Address
First Line	:	1807 3RD AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94606-1803
Country	:	US
Telephone Number	:	510-444-1969
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SERENE DAWN NGIN
Credential	:	OD
Telephone Number	:	510-444-1969

Provider Enumeration Date	:	04/11/2015
Last Update Date	:	04/11/2015

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Directions to “LAKE MERRITT OPTOMETRY ” Practice Location

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