Provider Demographics
NPI:1831113034
Name:MEYERSON, IVOR (OD)
Entity Type:Individual
Prefix:
First Name:IVOR
Middle Name:
Last Name:MEYERSON
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 1:1815 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278
Mailing Address - Country:US
Mailing Address - Phone:310-542-2251
Mailing Address - Fax:310-542-2362
Practice Address - Street 1:1815 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278
Practice Address - Country:US
Practice Address - Phone:310-542-2251
Practice Address - Fax:310-542-2362
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7011TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070110Medicaid
CAT70165Medicare UPIN
CAOP7011Medicare PIN
CA0589730001Medicare NSC