Provider Demographics
NPI:1790976066
Name:IRISH, TREVOR KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:KEITH
Last Name:IRISH
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 1:991 E MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-0636
Mailing Address - Country:US
Mailing Address - Phone:209-634-8591
Mailing Address - Fax:209-634-8596
Practice Address - Street 1:991 E MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-0636
Practice Address - Country:US
Practice Address - Phone:209-634-8591
Practice Address - Fax:209-634-8596
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2533152W00000X
OR3257ATI152W00000X
CA13477T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5033839Medicaid
CADB428AOtherMEDICARE GROUP PTAN
CA5033839Medicaid
CADB428AOtherMEDICARE GROUP PTAN