Provider Demographics
NPI:1346423753
Name:PRICKETT, MELISSA (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PRICKETT
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 1:23592 VIA PALOMA
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-4123
Mailing Address - Country:US
Mailing Address - Phone:949-637-8859
Mailing Address - Fax:
Practice Address - Street 1:2 JOURNEY STE 103
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3372
Practice Address - Country:US
Practice Address - Phone:949-362-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13413T152W00000X
CAOPT13413T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist