MEDICARE: ANIKA DEWAN O.D. INC.

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	OPT13802TLG	CA

General Provider Information

NPI Number	:	1740552447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANIKA DEWAN O.D. INC.

Provider Business Mailing Address
First Line	:	25039 WINTERGREEN CT
Second Line	:
City	:	NEWHALL
State	:	CA
Zip	:	91381-2214
Country	:	US
Telephone Number	:	714-496-9246
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 COLORADO AVE
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2318
Country	:	US
Telephone Number	:	310-393-5503
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANIKA DEWAN
Credential	:
Telephone Number	:	714-496-9246

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/27/2012

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