Provider Demographics
NPI:1952402026
Name:WATANABE, TERUO (OD)
Entity Type:Individual
Prefix:DR
First Name:TERUO
Middle Name:
Last Name:WATANABE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S MYRTLE AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-6139
Mailing Address - Country:US
Mailing Address - Phone:626-359-3937
Mailing Address - Fax:626-358-5030
Practice Address - Street 1:525 S MYRTLE AVE STE 107
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-6139
Practice Address - Country:US
Practice Address - Phone:626-359-3937
Practice Address - Fax:626-358-5030
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5612T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952402026OtherIND. NPI
CA1285726877OtherGROUP NPI
CASD0056120Medicaid
CA1285726877OtherGROUP NPI
CAT70050Medicare UPIN
CA0837360001Medicare NSC