Provider Demographics
NPI:1184146094
Name:SCOVILL, ALEXANDRA LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:LYNN
Last Name:SCOVILL
Suffix:
Gender:F
Credentials:OD
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Other - Credentials:
Mailing Address - Street 1:CASTILLEJOS EYE INSTITUTE MEDICAL GROUP
Mailing Address - Street 2:342 F STREET
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2625
Mailing Address - Country:US
Mailing Address - Phone:619-422-1471
Mailing Address - Fax:619-422-0114
Practice Address - Street 1:CASTILLEJOS EYE INSTITUTE MEDICAL GROUP
Practice Address - Street 2:342 F STREET
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-422-1471
Practice Address - Fax:619-422-0114
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33711-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT33711-TLGOtherOPTOMETRY LICENSE