Provider Demographics
NPI:1659436426
Name:FALLON MIJAILOVIC, KATHRYN A (OD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:FALLON MIJAILOVIC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:A
Other - Last Name:FALLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6700 FALLBROOK AVE
Mailing Address - Street 2:STE 190
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-3530
Mailing Address - Country:US
Mailing Address - Phone:818-346-2500
Mailing Address - Fax:818-346-2514
Practice Address - Street 1:555 SHOPS AT MISSION VIEJO
Practice Address - Street 2:STE 30 SHOPS AT MISSION VIEJO
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-4010
Practice Address - Fax:949-364-4001
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9843T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU33055Medicare UPIN