Provider Demographics
NPI:1235615014
Name:VERDUZCO DAVIS, CHANTELLE (OD)
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:
Last Name:VERDUZCO DAVIS
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 1:3404 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2428
Mailing Address - Country:US
Mailing Address - Phone:619-431-5393
Mailing Address - Fax:
Practice Address - Street 1:3404 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2428
Practice Address - Country:US
Practice Address - Phone:619-431-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34150TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist