MEDICARE: VANESSA JEAN EWING O.D.

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	18003453A	IN
2	152W00000X	Optometrist	OPT33920TLG	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780874453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA JEAN EWING O.D.

Provider Business Mailing Address
First Line	:	3855 BROAD ST STE B
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7109
Country	:	US
Telephone Number	:	805-545-8100
Fax Number	:	805-548-8785

Provider Business Practice Location Address
First Line	:	3855 BROAD ST., SUITE B
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7109
Country	:	US
Telephone Number	:	805-545-8100
Fax Number	:	805-548-8785

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

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	07/10/2019

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