Provider Demographics
NPI:1336614833
Name:MAGBANUA, ANDREA QUIMPO (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:QUIMPO
Last Name:MAGBANUA
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 1:171 W 223RD ST APT 6
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3734
Mailing Address - Country:US
Mailing Address - Phone:310-592-9700
Mailing Address - Fax:
Practice Address - Street 1:171 W 223RD ST APT 6
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3734
Practice Address - Country:US
Practice Address - Phone:310-592-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34107TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist