Provider Demographics
NPI:1326557109
Name:OLD NEWPORT OPTOMETRIC ASSOCIATES
Entity Type:Organization
Organization Name:OLD NEWPORT OPTOMETRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-650-9060
Mailing Address - Street 1:522 OLD NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4212
Mailing Address - Country:US
Mailing Address - Phone:949-650-9060
Mailing Address - Fax:
Practice Address - Street 1:522 OLD NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4212
Practice Address - Country:US
Practice Address - Phone:949-650-9060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9344TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty