Provider Demographics
NPI:1295751642
Name:ODISH, AMAAL (OD)
Entity type:Individual
Prefix:DR
First Name:AMAAL
Middle Name:
Last Name:ODISH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5364
Mailing Address - Country:US
Mailing Address - Phone:619-447-1139
Mailing Address - Fax:619-447-6239
Practice Address - Street 1:844 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-5364
Practice Address - Country:US
Practice Address - Phone:619-447-1139
Practice Address - Fax:619-447-6239
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11379TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0113790Medicaid
CAOP11379Medicare ID - Type Unspecified
CASD0113790Medicaid
CAU85075Medicare UPIN