Provider Demographics
NPI:1962461541
Name:ICHIUJI, JUDY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:LYNN
Last Name:ICHIUJI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:LYNN
Other - Last Name:MONJI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:153 N SAN FERNANDO BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1208
Mailing Address - Country:US
Mailing Address - Phone:818-848-6659
Mailing Address - Fax:818-848-7911
Practice Address - Street 1:153 N SAN FERNANDO BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1208
Practice Address - Country:US
Practice Address - Phone:818-848-6659
Practice Address - Fax:818-848-7911
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0100400Medicaid
CAFA823ZMedicare PIN
CASD0100400Medicaid