Provider Demographics
NPI:1689274433
Name:MICHAEL D MAGDATO OD
Entity Type:Organization
Organization Name:MICHAEL D MAGDATO OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAGDATO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-651-6987
Mailing Address - Street 1:5237 ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1308
Mailing Address - Country:US
Mailing Address - Phone:909-625-6567
Mailing Address - Fax:
Practice Address - Street 1:5237 ARROW HWY
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1308
Practice Address - Country:US
Practice Address - Phone:909-625-6567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-30
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5700641Medicaid