Provider Demographics
NPI:1174241103
Name:DEL REAL, EVELYN (OD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:DEL REAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2726 SOMERSET PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2277
Mailing Address - Country:US
Mailing Address - Phone:408-644-3626
Mailing Address - Fax:
Practice Address - Street 1:12100 WILSHIRE BLVD STE 1275
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7143
Practice Address - Country:US
Practice Address - Phone:800-485-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT35149-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist