Provider Demographics
NPI:1619085149
Name:GIN, STACEY T (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:T
Last Name:GIN
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 1:308 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1011
Mailing Address - Country:US
Mailing Address - Phone:818-243-1300
Mailing Address - Fax:818-243-1583
Practice Address - Street 1:308 E BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1011
Practice Address - Country:US
Practice Address - Phone:818-243-1300
Practice Address - Fax:818-243-1583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6057140001Medicare NSC
CAWOP13022AMedicare PIN