Provider Demographics
NPI:1508065020
Name:MEJIA, GUADALUPE ANGELICA JR (OD)
Entity Type:Individual
Prefix:DR
First Name:GUADALUPE
Middle Name:ANGELICA
Last Name:MEJIA
Suffix:JR
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY STE 290
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2040
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:301 E MUHAMMAD ALI BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1511
Practice Address - Country:US
Practice Address - Phone:502-852-5466
Practice Address - Fax:502-852-4947
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007185152W00000X
KY1750DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100114440Medicaid
KYK005731Medicare PIN