Provider Demographics
NPI:1073528949
Name:GANNAM, RACHEL M (OD)
Entity type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:M
Last Name:GANNAM
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:155 E WILBUR RD STE 101
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-7929
Mailing Address - Country:US
Mailing Address - Phone:805-497-7840
Mailing Address - Fax:805-373-0577
Practice Address - Street 1:155 E WILBUR RD STE 101
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7929
Practice Address - Country:US
Practice Address - Phone:805-497-7840
Practice Address - Fax:805-373-0577
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOPT13020152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist