Provider Demographics
NPI:1326019027
Name:AMAAL ODISH OD INC
Entity Type:Organization
Organization Name:AMAAL ODISH OD INC
Other - Org Name:ADVANCED VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO DOCTOR OF OPTOMETRY
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMAAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ODISH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-447-1139
Mailing Address - Street 1:844 EAST WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020
Mailing Address - Country:US
Mailing Address - Phone:619-447-1139
Mailing Address - Fax:619-447-6239
Practice Address - Street 1:844 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-447-1139
Practice Address - Fax:619-447-6239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11379TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0113790Medicaid
CACA1379OtherEYEMED
U85075Medicare UPIN
CA5399950001Medicare NSC
CAOP11379Medicare ID - Type Unspecified