Provider Demographics
NPI:1639361611
Name:DAVID G KIRSCHEN OD PHD A PROFESSIONAL OPTOMETRIC CORP
Entity Type:Organization
Organization Name:DAVID G KIRSCHEN OD PHD A PROFESSIONAL OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:KIRSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PHD
Authorized Official - Phone:714-529-2470
Mailing Address - Street 1:428 S BREA BLVD
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5301
Mailing Address - Country:US
Mailing Address - Phone:714-529-2470
Mailing Address - Fax:866-801-4739
Practice Address - Street 1:428 S BREA BLVD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5301
Practice Address - Country:US
Practice Address - Phone:714-529-2470
Practice Address - Fax:866-801-4739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP5418T152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X
CAOP13003T152WL0500X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6156150001Medicare NSC
CAW18668Medicare PIN