Provider Demographics
NPI:1467617175
Name:WATANABE, ALYSA E (OD)
Entity Type:Individual
Prefix:DR
First Name:ALYSA
Middle Name:E
Last Name:WATANABE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S MYRTLE AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5103
Mailing Address - Country:US
Mailing Address - Phone:626-359-3937
Mailing Address - Fax:
Practice Address - Street 1:525 S MYRTLE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-5103
Practice Address - Country:US
Practice Address - Phone:626-359-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13555152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFV539ZMedicare PIN