Provider Demographics
NPI:1750385787
Name:VIRAMONTES, DAWN M (OD)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:M
Last Name:VIRAMONTES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:M
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:805 W F ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3628
Mailing Address - Country:US
Mailing Address - Phone:209-847-0936
Mailing Address - Fax:209-847-9685
Practice Address - Street 1:805 W F ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3628
Practice Address - Country:US
Practice Address - Phone:209-847-0936
Practice Address - Fax:209-847-9685
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10745T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA500107450Medicaid
CA500107450Medicaid
CASD0107450Medicare PIN
CA500107450Medicare PIN
U65972Medicare UPIN