Provider Demographics
NPI:1225197163
Name:FARTASH, BECKY (OD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:
Last Name:FARTASH
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 1:734 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880
Mailing Address - Country:US
Mailing Address - Phone:951-737-2020
Mailing Address - Fax:951-737-2072
Practice Address - Street 1:734 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92880
Practice Address - Country:US
Practice Address - Phone:951-737-2020
Practice Address - Fax:951-737-2072
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7415T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074150Medicaid
CASD007415Medicare PIN
CASD0074150Medicaid