Provider Demographics
NPI:1912141441
Name:CARMEN JAN YOO
Entity Type:Organization
Organization Name:CARMEN JAN YOO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:714-894-5556
Mailing Address - Street 1:15057 GOLDENWEST ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-2710
Mailing Address - Country:US
Mailing Address - Phone:714-894-5556
Mailing Address - Fax:714-895-3126
Practice Address - Street 1:15057 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2710
Practice Address - Country:US
Practice Address - Phone:714-894-5556
Practice Address - Fax:714-895-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11663TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005590Medicaid
CAOP11663Medicare UPIN
CA6220870001Medicare NSC
CAGSD005590Medicaid