Provider Demographics
NPI:1679336192
Name:GAO, IAN CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:CHARLES
Last Name:GAO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:IAN
Other - Middle Name:CHARLES
Other - Last Name:GAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:511 BISHOP DR
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-3004
Mailing Address - Country:US
Mailing Address - Phone:562-713-0138
Mailing Address - Fax:
Practice Address - Street 1:5899 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-6866
Practice Address - Country:US
Practice Address - Phone:916-534-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist