Provider Demographics
NPI:1497786156
Name:DORTCH, DAVID A (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:DORTCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39252 WINCHESTER RD
Mailing Address - Street 2:STE. 127
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-3509
Mailing Address - Country:US
Mailing Address - Phone:951-600-9226
Mailing Address - Fax:866-268-5876
Practice Address - Street 1:39252 WINCHESTER RD
Practice Address - Street 2:STE. 127
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-3509
Practice Address - Country:US
Practice Address - Phone:951-600-9226
Practice Address - Fax:866-268-5876
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10758T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0107580Medicaid
CAU43745Medicare UPIN
CASD0107580Medicaid