Provider Demographics
NPI:1689730012
Name:KATHLEEN DENNIS-ZARATE MD
Entity Type:Organization
Organization Name:KATHLEEN DENNIS-ZARATE MD
Other - Org Name:THE SPECTACLE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:DENNIS ZARATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-249-6447
Mailing Address - Street 1:2330 HONOLULU AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1822
Mailing Address - Country:US
Mailing Address - Phone:818-249-6447
Mailing Address - Fax:818-249-0547
Practice Address - Street 1:2330 HONOLULU AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1822
Practice Address - Country:US
Practice Address - Phone:818-551-7127
Practice Address - Fax:818-249-0547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81715207W00000X
CAG81539207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095000Medicaid
CAW16156Medicare ID - Type UnspecifiedMEDICARE GROUP
CAGR0095000Medicaid
CAG08243Medicare UPIN