Provider Demographics
NPI:1194860270
Name:MISCHENKO, PHILIP ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALAN
Last Name:MISCHENKO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 STONEHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-1622
Mailing Address - Country:US
Mailing Address - Phone:626-355-1543
Mailing Address - Fax:626-286-9214
Practice Address - Street 1:5825 TEMPLE CITY BLVD
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-2113
Practice Address - Country:US
Practice Address - Phone:626-286-9214
Practice Address - Fax:626-296-9231
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7015T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist