Provider Demographics
NPI:1396829073
Name:DAVID A. DORTCH,O.D. A CALIFORNIA PROFESSIONAL OPTEMETRIC CORPORATION
Entity Type:Organization
Organization Name:DAVID A. DORTCH,O.D. A CALIFORNIA PROFESSIONAL OPTEMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DORTCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-600-9226
Mailing Address - Street 1:39252 WINCHESTER ROAD
Mailing Address - Street 2:STE 127
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-3511
Mailing Address - Country:US
Mailing Address - Phone:951-600-9226
Mailing Address - Fax:866-268-5876
Practice Address - Street 1:39252 WINCHESTER ROAD
Practice Address - Street 2:STE 127
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-3511
Practice Address - Country:US
Practice Address - Phone:951-600-9226
Practice Address - Fax:866-268-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5561620001Medicare NSC
CAZZZ047362Medicare PIN
CAU43745Medicare UPIN