Provider Demographics
NPI:1356491021
Name:IKEMOTO, LANCE M (OD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:M
Last Name:IKEMOTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9337 MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1924
Mailing Address - Country:US
Mailing Address - Phone:909-624-6809
Mailing Address - Fax:909-624-7487
Practice Address - Street 1:2056 WESTMINSTER MALL
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4947
Practice Address - Country:US
Practice Address - Phone:714-897-0996
Practice Address - Fax:714-897-3596
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0105300Medicare ID - Type Unspecified
CAU91269Medicare UPIN