Provider Demographics
NPI:1053487033
Name:MONDOUX, NICOLE MARIE (OP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MONDOUX
Suffix:
Gender:F
Credentials:OP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4225
Practice Address - Street 1:3060 E 9TH ST STE B
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2925
Practice Address - Country:US
Practice Address - Phone:510-535-5500
Practice Address - Fax:510-535-4225
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124035159OtherSITE NPI
1124035159OtherSITE NPI