Provider Demographics
NPI:1932294733
Name:DO, DAT T (OD)
Entity Type:Individual
Prefix:DR
First Name:DAT
Middle Name:T
Last Name:DO
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 1:1261 CABRILLO AVE
Mailing Address - Street 2:#200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2868
Mailing Address - Country:US
Mailing Address - Phone:310-618-2244
Mailing Address - Fax:
Practice Address - Street 1:1261 CABRILLO AVE
Practice Address - Street 2:#200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2868
Practice Address - Country:US
Practice Address - Phone:310-618-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11846T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1932294733Medicaid
CAW17346Medicare PIN