Provider Demographics
NPI:1891268678
Name:17TH STREET OPTOMETRY APC
Entity Type:Organization
Organization Name:17TH STREET OPTOMETRY APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:ELSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-338-7027
Mailing Address - Street 1:17300 17TH ST STE M
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1955
Mailing Address - Country:US
Mailing Address - Phone:714-838-9664
Mailing Address - Fax:714-838-6774
Practice Address - Street 1:17300 17TH ST STE M
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1955
Practice Address - Country:US
Practice Address - Phone:714-838-9664
Practice Address - Fax:714-838-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty