Provider Demographics
NPI:1780789818
Name:AZEVEDO, LOREN MARTIN (O D)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:MARTIN
Last Name:AZEVEDO
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 BAYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6769
Mailing Address - Country:US
Mailing Address - Phone:707-822-7641
Mailing Address - Fax:707-822-5883
Practice Address - Street 1:851 BAYSIDE RD
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6769
Practice Address - Country:US
Practice Address - Phone:707-822-7641
Practice Address - Fax:707-822-5883
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6395T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDOO63950Medicare ID - Type Unspecified
CAT10310Medicare UPIN