Provider Demographics
NPI:1417260506
Name:DEBORAH PRINCE O D AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:DEBORAH PRINCE O D AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-224-2973
Mailing Address - Street 1:3150 ROSECRANS PL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3150 ROSECRANS PL
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4823
Practice Address - Country:US
Practice Address - Phone:619-224-2973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12242TPA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
U94991Medicare UPIN