Provider Demographics
NPI:1679638928
Name:GIACALONE, VIC I (OD)
Entity Type:Individual
Prefix:
First Name:VIC
Middle Name:I
Last Name:GIACALONE
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 1:1150 W CAPITOL DR
Mailing Address - Street 2:#107
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-5015
Mailing Address - Country:US
Mailing Address - Phone:510-514-8435
Mailing Address - Fax:
Practice Address - Street 1:1815 HAWTHORNE BLVD
Practice Address - Street 2:STE 236
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3424
Practice Address - Country:US
Practice Address - Phone:310-370-1618
Practice Address - Fax:310-371-3126
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12143T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91339Medicare UPIN
CAWOP12143Medicare ID - Type Unspecified