Provider Demographics
NPI:1467119115
Name:MOUAWAD, GUY T (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:GUY
Middle Name:T
Last Name:MOUAWAD
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W FOOTHILL BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3339
Mailing Address - Country:US
Mailing Address - Phone:626-335-5815
Mailing Address - Fax:
Practice Address - Street 1:345 W FOOTHILL BLVD STE E
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3339
Practice Address - Country:US
Practice Address - Phone:626-335-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL2668156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician