Provider Demographics
NPI:1659387595
Name:GUERRERO, MIGUEL L (OD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:L
Last Name:GUERRERO
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 1:1880 COLLEGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4436
Mailing Address - Country:US
Mailing Address - Phone:323-261-5942
Mailing Address - Fax:
Practice Address - Street 1:4403 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2413
Practice Address - Country:US
Practice Address - Phone:323-232-1234
Practice Address - Fax:323-232-3789
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5531 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055310Medicaid