Provider Demographics
NPI:1457495913
Name:YOO-BOURGOIN, JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:YOO-BOURGOIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:YOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1835 NEWPORT BLVD
Mailing Address - Street 2:STE E270
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-646-4949
Mailing Address - Fax:949-646-2533
Practice Address - Street 1:1835 NEWPORT BLVD
Practice Address - Street 2:STE E270
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-5014
Practice Address - Country:US
Practice Address - Phone:949-646-4949
Practice Address - Fax:949-646-2533
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10185T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548472921OtherGROUP NPI (TYPE 2)