MEDICARE: VANESSA QUYNH ISHIDA OD

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	35097	CA
2	152W00000X	Optometrist	35097TLG	CA

General Provider Information

NPI Number	:	1770239709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA QUYNH ISHIDA OD

Provider Business Mailing Address
First Line	:	254 BALLENA DR
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-1703
Country	:	US
Telephone Number	:	714-548-0694
Fax Number	:

Provider Business Practice Location Address
First Line	:	16855 VALLEY BLVD STE A-B
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92335-6621
Country	:	US
Telephone Number	:	909-320-6667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	01/05/2024

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