Provider Demographics
NPI:1720167794
Name:ATIZ, MICHELE ANGELA (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ANGELA
Last Name:ATIZ
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 1:1035 S GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-3330
Mailing Address - Country:US
Mailing Address - Phone:909-623-6766
Mailing Address - Fax:909-623-8070
Practice Address - Street 1:1035 S GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-3330
Practice Address - Country:US
Practice Address - Phone:909-623-6766
Practice Address - Fax:909-623-8070
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12106T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0121061Medicaid
CAOP12106Medicare ID - Type Unspecified