Provider Demographics
NPI:1851404040
Name:WATANABE, DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:
Last Name:WATANABE
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 1:75 REMITTANCE DR
Mailing Address - Street 2:DEPT 6008
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:4476 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6359
Practice Address - Country:US
Practice Address - Phone:323-563-9499
Practice Address - Fax:323-563-9056
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7702T152W00000X
CA7702T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD007020Medicaid
CASD0077020Medicaid
CA410046776OtherMEDICARE RAILROAD
CA00OPT7702T0OtherBLUE SHIELD
CA410046776OtherRAILROAD MEDICARE
CA410046776OtherMEDICARE RAILROAD
CAWOP7702CMedicare PIN