Provider Demographics
NPI:1598752883
Name:HOM, PERRY S (OD)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:S
Last Name:HOM
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 1:592 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3467
Mailing Address - Country:US
Mailing Address - Phone:626-331-6448
Mailing Address - Fax:
Practice Address - Street 1:364 E ROWLAND ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3154
Practice Address - Country:US
Practice Address - Phone:626-331-6448
Practice Address - Fax:626-967-7006
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8497T152W00000X
OR2327T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T97026Medicare UPIN
WOP8497AMedicare ID - Type Unspecified