Provider Demographics
NPI:1790768794
Name:IMAMOTO, NANCY TANG (OD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:TANG
Last Name:IMAMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 W ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3220
Mailing Address - Country:US
Mailing Address - Phone:310-329-4128
Mailing Address - Fax:310-329-9180
Practice Address - Street 1:1713 W ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3220
Practice Address - Country:US
Practice Address - Phone:310-329-4128
Practice Address - Fax:310-329-9180
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11361T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16618OtherMEDICAL EYE SERVICES
CACA1361OtherEYEMED