Provider Demographics
NPI:1164536041
Name:QUINTANA, PHYLLIS (OD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:
Last Name:QUINTANA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:M
Other - Last Name:QUINTANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:907 WEST 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030
Mailing Address - Country:US
Mailing Address - Phone:805-487-0609
Mailing Address - Fax:805-487-8330
Practice Address - Street 1:907 WEST 7TH ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030
Practice Address - Country:US
Practice Address - Phone:805-487-0609
Practice Address - Fax:805-487-8330
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5585TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
500055850OtherMEDICAL
6701OtherMEDICAL EYE SERVICES
6648OtherGOLDEN WEST
953833691OtherVSP
6701OtherNNES
116524OtherEYE MED
953833691OtherTRI CARE
953833691OtherBLUE SHIELD OF CA
953833691OtherBLUE SHIELD OF CA
953833691OtherVSP