MEDICARE: DR. JUSTIN TADASHI ABO 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	11100T	CA

General Provider Information

NPI Number	:	1952386963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN TADASHI ABO OD

Provider Business Mailing Address
First Line	:	12759 FOOTHILL BLVD
Second Line	:	STE C
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9336
Country	:	US
Telephone Number	:	909-899-0026
Fax Number	:	909-899-6381

Provider Business Practice Location Address
First Line	:	12759 FOOTHILL BLVD
Second Line	:	STE C
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9336
Country	:	US
Telephone Number	:	909-899-0026
Fax Number	:	909-899-6381

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

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	06/19/2014

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