1891874301 NPI number — DR. TERRY METSOVAS O.D.

Table of content: DR. TERRY METSOVAS O.D. (NPI 1891874301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891874301 NPI number — DR. TERRY METSOVAS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
METSOVAS
Provider First Name:
TERRY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891874301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92863-6512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-637-9999
Provider Business Mailing Address Fax Number:
714-637-9993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2097 N TUSTIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92865-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-637-9999
Provider Business Practice Location Address Fax Number:
714-637-9993
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT. 10460 TPA , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5302020001 . This is a "DMERC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 61327 . This is a "SAFEGUARD PPO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 9358503 . This is a "PHCS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 207199 . This is a "EYEMED VISION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 61328 . This is a "SAFEGUARD HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CA10460 . This is a "VISION BENEFITS AMERICA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD01046T1 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 13607 . This is a "MEDICAL EYE SERVICE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 19173 . This is a "COAST TO COAST VISION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0104600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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