Provider Demographics
NPI:1295933695
Name:GENDELMAN PATEL, IRENE (OD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:GENDELMAN PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:GENDELMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:415 EVENING VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-5212
Mailing Address - Country:US
Mailing Address - Phone:858-405-9484
Mailing Address - Fax:
Practice Address - Street 1:9349 MISSION GORGE RD
Practice Address - Street 2:114
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3886
Practice Address - Country:US
Practice Address - Phone:858-405-9484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABW957ZMedicare PIN