Provider Demographics
NPI:1588654719
Name:ABO, LAUREN AKEMI (OD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:AKEMI
Last Name:ABO
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 1:15290 SUMMIT AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0240
Mailing Address - Country:US
Mailing Address - Phone:909-646-9800
Mailing Address - Fax:909-646-9111
Practice Address - Street 1:6945 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1754
Practice Address - Country:US
Practice Address - Phone:619-697-4600
Practice Address - Fax:619-464-5526
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0052930Medicaid
CAOPT11503OtherSTATE LICENSE NUMBER
CAGR0052930Medicaid