Provider Demographics
NPI:1932196227
Name:KLIMEK, EDYTA (OD)
Entity Type:Individual
Prefix:DR
First Name:EDYTA
Middle Name:
Last Name:KLIMEK
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 1:27451 LA PAZ RD STE B
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4082
Mailing Address - Country:US
Mailing Address - Phone:949-643-2020
Mailing Address - Fax:949-643-9061
Practice Address - Street 1:27451 LA PAZ RD STE B
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4082
Practice Address - Country:US
Practice Address - Phone:949-643-2020
Practice Address - Fax:949-643-9061
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1369152W00000X
CA12594T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB217108Medicare PIN
AZV01292Medicare UPIN
AZ79647Medicare ID - Type UnspecifiedMEDICARE/MEDICAID