Provider Demographics
NPI:1063518181
Name:CARMEN JAN YOO, OD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CARMEN JAN YOO, OD A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:JAN
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-525-3330
Mailing Address - Street 1:1319 S HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-3001
Mailing Address - Country:US
Mailing Address - Phone:714-525-3330
Mailing Address - Fax:714-525-3334
Practice Address - Street 1:1319 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3001
Practice Address - Country:US
Practice Address - Phone:714-525-3330
Practice Address - Fax:714-525-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11663T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005590Medicaid
CAU86982Medicare UPIN
CAGSD005590Medicaid
CA6220870002Medicare NSC
CAWOP11663IMedicare PIN